Nurses’ work with HIV prevention among women at Mpongwe Mission Hospital in Zambia

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Examensarbete i omvårdnad Malmö högskola

Nivå 61-90 p Hälsa och samhälle

Sjuksköterskeprogrammet 205 06 Malmö

Juni 2011

Hälsa och samhälle

NURSES’

WORK

WITH

HIV

PREVENTION

AMONG

WOMEN

AT

MPONGWE

MISSION

HOSPITAL

IN

ZAMBIA

AN INTERVIEW STUDY

CHARLOTTA SIMMONS

SOFIE SINTÉUS

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NURSES’

WORK

WITH

HIV

PREVENTION

AMONG

WOMEN

AT

MPONGWE

MISSION

HOSPITAL

IN

ZAMBIA

AN INTERVIEW STUDY

CHARLOTTA SIMMONS

SOFIE SINTÉUS

Simmons, C & Sintéus, S. The HIV prevention among women at Mpongwe Mission Hospital in Zambia. An interview study. Degree project, 15 credit points. Nursing program, Malmö Högskola: Health and Society, Department of nursing 2011.

Background: Zambia has one of the world’s most devastating HIV/AIDS epidemics and

nurses work hard to spread information about how to prevent the infection. Females are more vulnerable since they often marry early to older men who already have a sexual past and also because they have larger permeability of the mucous membrane compared to men. The nurses play an important role in the prevention work and how it’s done.

Objective: The aim of the study is to explore the nurse’s prevention work against HIV among

women at the Mpongwe Mission Hospital.

Methods: A semistructured design in a qualitative study, carried out at Mpongwe Misson

Hospital in Zambia. The result has been analyzed through Burnards method of description of content analysis.

Result: The result of this study is divided in five different categories concerning guidelines in

the HIV-prevention, measures to reduce the risk of HIV-infection, how they reach out to people, the obstacles and challenges that the nurses are facing and the progress that is made.

Conclusion: The interviews shows that the Nurses in this study at Mpongwe Hospotal are

working hard to prevent HIV among women. They have come a long way in their prevention work although there is much left to do. The wide spread of knowledge among the nurses and the lack of staff is big obstacle. Because of the shortage of finances the hospital can´t afford to send nurses for further education or hire enough staff to be able to give the right care and to reach out to the population.

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SJUKSKÖTERSKORS

ARBETE

MED

HIV

PREVENTION

BLAND

KVINNOR

PÅ

MPONGWE

MISSIONS

SJUKHUS

I

ZAMBIA

EN INTERVJU STUDIE

CHARLOTTA SIMMONS

SOFIE SINTÉUS

Simmons, C & Sintéus, S. HIV prevention av kvinnor på Mpongwe Missions Sjukhus i Zambia. En intervju studie. Examensarbete i omvårdnad 15 högskolepoäng. Malmö högskola: Hälsa och samhälle, Utbildningsområde omvårdnad 2011.

Bakgrund: Zambia är ett av de länder i världen som är värst drabbat av HIV/AIDS och

sjuksköterskor i landet jobbar ständigt med att spridda preventiv information om infektionen. Kvinnor är mer sårbara då de ofta gifter sig med äldre män som redan har ett sexuellt förflutet men också p.g.a. att de har större permeabilitet i mucosa membranet än vad män har.

Sjuksköterskorna spelar en viktig roll i preventionsarbetet och dess funktion.

Syfte: Syftet med studien är att utforska sjuksköterskors arbete med HIV prevention bland

kvinnor på Mpongwe missions sjukhus.

Metod: En kvalitativ studie med semistrukturerade intervjuer med 8 sjuksköterskor

genomförd på Mpongwe missions sjukhus i Zambia. Resultatet har analyserats med hjälp av Burnards innehållsmetods analys.

Resultat: Resultatet av studien utmynnade i fem olika kategorier rörande riktlinjer vid

HIV-prevention, metoder för att minska risken av HIV-spridning, hur de når ut till folket, svårigheter och utmaningar som sjuksköterskorna möter men även de framsteg som görs.

Slutsats: Intervjuerna med sjuksköterskorna på Mpongwe Missions sjukhus visar att de jobbar

hårt med att förebygga HIV bland kvinnor. De har kommit långt i sitt arbete men det finns fortfarande mycket kvar att göra. Den stora spridningen på kunskap hos sjuksköterskorna och bristen på personal är ett stort problem. På grund av att de har ont om finanser har sjukhuset inte råd att skicka sina sjuksköterskor på fler utbildningar eller att anställa mer personal för att kunna ge rätt vård och nå ut till människorna.

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TABLE OF CONTENT

INTRODUCTION 6 BACKGROUND 7 HIV/AIDS 7 Transmission 7 HIV/AIDS in Zambia 8

The impact on Women 8

Prevention work of HIV 8

Mpongwe mission area 9

The Hospital 9

ART Clinic and HIV/AIDS program at the Mpongwe Mission Hospital 10

AIM OF THE STUDY 10

Definition 10

METHOD 11

Sample 11

Data collection 11

Trustworthiness 12

Analysis of the research data 13

Ethical considerations 15

Information and approval 15

Ethical permission 16

RESULT 16

Guidelines 17

Interventions to reduce the risk of HIV-infection 17

Information and education 17

Contraceptives 18

Testing for HIV 18

Importance of nursing competence 19

Reaching out to the people 19

Healthcommunities 19

Outreach 20

Obstacles and challenges 20

Misconceptions 20

Stigma 21

Early marriage and pregnancy 21

Poor financing 22

Progress 23

Small steps ahead 23

What could make the HIV-preventionwork at Mpongwe Mission Hospital better? 24

DISCUSSION 25

Result discussion 25

Guidelines 25

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Reaching out to the people 27

Obstacles and challenges 28

Progress 29 Method discussion 30 Selection 30 Data collection 31 Data analysis 32 CONCLUSIONS 32 REFERENCES 34 APPENDIX 37 Appendix 1 38 Appendix 2 39 Appendix 3 40

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INTRODUCTION

The first thing you see when entering the Mpongwe Mission Hospital in Zambia is all the people. There is an outside waiting room, which is filled and all around on the ground, on the grass and under the trees people are waiting to be seen by a doctor. By the end of the day the waiting room is empty and all the patients have been taken care of. It’s not always easy though, with a hospital that is struggling with a shortage of finances, which is the main reason for not having enough nurses, medicine, medical supplies and vehicles for transporting. The hospital has four different wards and on each ward one nurse is working each shift. This leads to a tight schedule with too much work for one single nurse. There are often many patients on a small area on the wards and the lack of isolation possibilities makes it hard to prevent contagious infections and diseases from spreading within the hospital. Hygiene is an aspect that the hospital also is working on and the hygiene routines aren’t as good as in developed countries.

Many of the patients have to walk to the hospital and a large number of them live more than an hour away by foot. When they finally come to the hospital they are often very sick and their disease have been progressing for a long time. A lot of the diseases can be mortal and among them is the HIV-infection.

HIV and AIDS is a great difficulty for our world today and the countries that are most affected is in the south of Africa, thereby Zambia (Björngren, 2010). There is no cure for HIV, which makes the prevention work even more important. Nurses play an important role in the preventive work and in the Swedish Health and Welfare Agency’s (Socialstyrelsen) official instructions for nurses says that they are required to work preventively and encourage health and fight sickness (Socialstyrelsen, 2005). This minor field study explores the nurse’s prevention work against HIV at the Mpongwe Mission Hospital in Zambia. The researchers spent six weeks during spring 2011 in the Mission area and were given a chance to see how the healthcare works by spending many hours at the hospital and by talking to the employees.

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BACKGROUND

The healthcare in Zambia is provided for by government institutions, the Churches health Associations of Zambia (CHAZ), the mining companies, parastatal organisations, private clinics and traditional healers. Zambia is experiencing a human resource crisis and the capability to provide healthcare services to the people is undermined. Currently the health sector is operating at 50 % of the capacity with almost 45 % of the rural health centre’s run by unqualified health workers. In the Northern Province the doctor to population ratio is as high as 1:69,000 compared to the World health Organizations recommended ratio of 1:5,000. Trying to solve this, the government has set up a human resource task force to develop an emergency human recourse rescue plan and criteria for implementation (Republic of Zambia, 2006).

HIV/AIDS

Human immunodeficiency virus (HIV) was first reported in 1981 in the USA and has ever since spread all over the world (Almås, 2006). According to the World health associations “10 facts on HIV/AIDS” 33.4 million people worldwide are infected with HIV. HIV is a virus that attacks the cells (T-lymphocytes) from our immunity system in the blood and changes the DNA in the cells by transferring their own genes into the cell. The virus is always going to be a part of an HIV infected person’s nuclear proteins. HIV has a very long latent period and the symptoms can be hidden for years. Normally it takes up to ten years before the immunity system falters and the infected person develops AIDS (Acquired Immune Deficiency

Syndrome). The body’s immunity system cannot defend itself from infections that will affect for example the skin, nervous system, respiratory organs and the gastric system (Ericsson & Ericsson, 2009).

Transmission

HIV exists in the body fluids of an infected person and is transmitted to another person through body fluids like blood, sperm and vaginal secretions that contains enough viruses to contaminate. Infection can occur by inoculation of infected blood for example syringes and needles, by sexual transfer, which is the most common transmission route and by transmission from mother to child during pregnancy, childbirth and lactation (Almås, 2006).

Both men and women can be infected with AIDS but particularly women, because women expose a larger genital surface area than men. Women have greater permeability of the mucous membranes of the vagina compared to those of the penis, and longer exposure of semen in the vaginal tract. Sexual transmitted diseases among women are often asymptomatic and the disease doesn´t get discovered which leads to lack of treatment (Baylies & Bujra, 2000).

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HIV/AIDS in Zambia

The countries that are most affected by HIV/AIDS are in the south of Africa. HIV/AIDS in Africa causes 32% of all deaths across the world (Björngren, 2010). Zambia has one of the world’s most devastating HIV and AIDS epidemics. Zambia’s first AIDS case was reported in 1984. In the early nineties it was estimated that 1 in 5 adults had been infected with HIV and in 2004 HIV/AIDS was declared a national emergency (avert.org, 2011-05-23).

Today more than 1 of 7 adults in Zambia are living with HIV (UNAIDS, 2008) and expects to live for 39 years (CIA, 2010). In 2009, nearly 83,000 adults were newly infected with HIV, which is about 200 new infections every day (Government Republic of Zambia, 2010). Although Zambia has received millions of dollars for HIV programs from other countries, prevalence rates are unfortunately not dropping and have remained quite stable since the nineties (avert.org).

The impact on Women

HIV does not primarily affect the most underprivileged people in Zambia. Infection rates are very high among wealthier and educated people. Citizens who are seeking work elsewhere, such as miners and seasonal agricultural workers, has been shown to spread HIV to new areas (Kandala et al, 2008).

Although the HIV epidemic has spread to all parts of society, some groups are more vulnerable such as young women and girls. Among young women aged 15-24, HIV prevalence is nearly four times higher than for men in this age category (UNAIDS, 2008). Young women in Zambia typically become sexually active earlier than men, with a partner who will be older than she and who may already have had a number of sexual partners (avert.org). Women are often taught never to refuse their husbands sex or to insist on using a condom (Kandala et al, 2008).

The use of contraceptives to prevent HIV-infection and unwanted pregnancies is still rare in Zambia. Research made in 2010 in Zambia concerning knowledge and use of modern family planning shows that the main reasons for non use of contraceptive methods were mostly because of religious beliefs (50%). The other reasons were partner’s disapproval (30%) and some of the women didn´t use contraceptive because of the side effects (20%) (Mubita- Ngoma, 2010).

Prevention work of HIV

There is no cure or vaccine for HIV/AIDS and the only way to decrease the spreading of the disease is to take control over the infections. To increase the knowledge of HIV/AIDS and to make people understand the risks, how the disease spreads and different ways of prevention is of most importance. To change the sexual activities in heterosexual relations, preventive information around three keymessages has been created: A-B-C, “Abstinence”, “Be faithful” and “use Condom”. Abstinence is intended for young people, for not having sexual relations before marriage. B and C stands for faithfulness and condom use to decrease the risk of HIV (Egerö et al, 2001). Condoms and abstinence are proven to be highly effective at preventing transmission of HIV. In 2002 the three main churches in Zambia passed a resolution

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encourage abstinence only. The AIDS experts consider this to be an ineffective approach and they want the churches to encourage condom use for everyone. Problems with condom as a prevention is that many can´t afford it, that they live too far away from the nearest outlet or the lack of knowledge (www.avert.org 2011-05-23).

Peoples’ knowledge about HIV/AIDS is still very poor. In 2007 almost two thirds of the 15-24 year olds could not correctly identify ways of preventing sexual transmission of HIV. Therefore education for these young people is most important so they can stay healthy. Not all teachers have enough knowledge to integrate information about HIV in their curriculum and the ministry is eager to change that (www.avert.org 2011-05-23).

The HIV-prevention work also focuses on pregnant women because 30% of the HIV-positive women transfer the virus to their babies. This includes prenatal care, offering antiretroviral drugs and education on feeding alternatives (Mc Gowan & Shah, 2000). In 1999 Zambia’s “prevention of mother to child transmission” initiative was launched. In 2004, 74 health facilities in four provinces could offer antiretroviral drugs to expectant mothers and newborn infants. This increased in just 4 years to 939 health facilities. In 2007 an estimated 47% of pregnant women living with HIV received antiretroviral drugs for preventing mother to child transmission. This number had by the end of 2009 increased to 61% (http://www.avert.org 2011-05-23).

Other effective methods to prevent the transmission of HIV is testing and counseling. If people know and understand their HIV-status most of them want to protect themselves, their family and the people around them. A positive change of actions might lead to reduction of the infection in areas that has high HIV-incidence (Killow et al, 1998). Further preventive measures can be information by radio, television and press. Not all people have direct access to them but it has proven to be influential in raising awareness about HIV (www.avert.org 2011-05-23).

Mpongwe mission area

The mission area started to develop in 1931 when missioners Johansson and Borg from Sweden came as pioneer missionaries from an Independent Baptist denomination in Sweden called “Fribaptistsamfundet”. They developed the school and church services and they were followed by many other Swedish missionaries who contributed to the work in Mpongwe mission area. The place that started as nothing but bush is now known as Mpongwe mission area (www.mpongwe.com 2011-05-23).

The Hospital

Three days after the Johansson family arrived to Mpongwe they had to treat a man who was injured by a leopard. At first he was treated under a tree but soon a small mud hut was built behind the church to serve as a clinic. Ten years later up to 14,000 patients were treated there. In 1950 two Swedish missionaries arrived to help making the healthcare more professional. The first buildings where patients could be admitted were put up and with the arrival of more nursing staff from Sweden the healthcare in Mpongwe mission area expanded quickly

(www.mpongwe.com 2011-05-23).

David Kallinga, The hospital information officer at the Mpongwe Mission Hospital informs the researchers that with payments partly from the government of Zambia and partly from the

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Mpongwe Mission, the hospital was officially opened in 1978. The staff today includes 6 Doctors, 33 nurses and midwifes, 4 clinical officers, 8 paramedics, 8 administrational workers and 52 support employees. The hospital had in 2010, 47 435 outpatients and 4997 patients that were being treated on the wards. In 2009, 31 500 patients came to Mpongwe Mission Hospital for treatment. This was a decrease of 27 300 patients since the prior year. This change of numbers from one year to another can be explained by the Malaria programs and preventive measures that have had a big effect in the area. The numbers of patients has decreased over the years but giving the patients the right care is still a challenge. High pressure on the hospital staff comes with the high number of patients.

The hospital has 27 health neighborhoods in the Mpongwe district and they are provided with one or two community health workers each. The health workers are trained by the hospital to provide basic healthcare to the people in these neighborhoods.

ART Clinic and HIV/AIDS program at the Mpongwe Mission Hospital

Kallingas’ statistics shows that in 2010, 1347 patients came to the hospital for HIV-testing, 502 of those were tested positive with the HIV-infection. The hospital has nationally

recommended protocols for HIV treatment. An ART clinic (Anti-Retroviral Therapy) with a program for patients with HIV has been started. The program includes over 1400 people who are receiving medication, support and ongoing counseling. With the ART program people get information about the virus and how to decrease the spread of the disease. The hospital is also working with the prevention of HIV through campaigns to reach out to the population about the importance of getting tested and with counseling for all patients on behavior and attitudes changes and through preventative measures for mother to child transmission

(www.mpongwe.com).

AIM OF THE STUDY

The aim of the study is to explore the nurses’ HIV prevention work among women at the Mpongwe Mission Hospital.

Definition

The concept prevention is often used within the field of disease prevention and is a term for measures aimed to maintain good health, prevent injuries and the occurrence of diseases and it´s spread (National Encyklopedin, 2010).

HIV is a virus that attacks the cells from our immunity system in the blood and changes the DNA in the cells by transferring their own genes into the cell (Ericsson & Ericsson, 2009).

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METHOD

In this study a qualitative design has been used. A qualitative research design is most of all flexible and elastic so that the researcher has the possibility to adjust to what is being learned during the course of data collection. By using this kind of study the investigator can decide from who they need to gather information and data, how to schedule data collection and how long each data collection session should last as the study develops.

A semi structured design has been used in the study. A semi structured design means that the researcher has a list of topics which needs to be addressed in the interview. By having a list of relevant questions during the interview the researchers can make sure that the information and data that needs to be gathered of a specific topic is being covered. This method can help the researcher to have a structured interview but also an opportunity to make changes when it comes to the questions form and sequence (Kvale, 1997). Healthcare is a complex operation with phenomenon that is difficult to measure. Through interviews phenomenon can be analyzed, highlighted and described (Dahlberg, 1997).

Sample

The criteria for participating in the study were: nurses, male and females, who have been working as nurses at Mpongwe Mission Hospital for more than three months, who have knowledge, insight and experience of working with the prevention of HIV and could understand and speak English. The researchers were given a gatekeeper who provided a contact between the researchers and the nurses during the morning meetings where they were given the information about the study. The nurses were also spoken to during their shifts and time for interviews was set according to their working schedules. Some of the interviews were also held on the nurse’s spare time due to their tight schedule at the hospital.

The respondents participating in this study were eight nurses, one male and seven females with a wide spread of age between 22 and 57 years of age with an average age of 32. The working experience varies from 4 months to 34 years with an average of 10 years. By choosing participants with various experience increases the possibility of getting answers of the research question from a variety of aspects (Graneheim, Lundman B, 2003).

The researchers used convenience sampling when choosing participants for the study. Polit & Beck (2006) describes convenience sampling as “selection of the readily available persons as participants in a study” (Polit & Beck, 2006, p 497). The nurses at Mpongwe Mission

Hospital had a tight working schedule and according to Polit & Beck (2006) convenience sample may be an efficient way to begin the sampling process.

Data collection

The researchers started gathering data between the 4th of April -18th of April 2011. A pilot interview was arranged with one of the nurses to test the interviewguide. The researchers were satisfied with the data they received from the pilot interview and it was therefore included in the study.

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The interviews took place during office hours in separate rooms on the wards where the nurse was working at the time. Since the employees had a full schedule some of the nurses chose to do the interview at their own house when they were off duty. Both authors were present during all the interviews but one of them was only observing while the other asked the questions. The

researchers shifted roles for each interview, so that they both were able to observe or ask questions. The interviews took 20- 45 minutes and they were all held in English. The nurse

education in Zambia is in English and it is also the standard language in medicine. Demographical questions involving age, gender, years of education, years working with the prevention of HIV, years of working experience were registered at each interview.

Data and information were registered by a voice recorder. Using a voice recorder is the most common way to register an interview and it gives the researcher a chance to concentrate on the flow of the interview. The words, the intonation of the voice, the pauses etc. is registered and gives the interviewers an opportunity to go back and listen to the interview if needed (Kvale, 1997). The researchers were also using an interview guide during the interviews (Appendix 3). After each interview the tape was transcripted, which means the recorded interviews were

transferred to text, since it’s difficult to handle data if it’s only on tape. The transcription must be as accurate as possible, so all pauses, laughs, coughs, hesitations etc. must be written down (Dahlberg, 1997).

Trustworthiness

According to Graneheim and Lundman (2003) the concepts credibility, dependability and

transferability are being used to describe various aspects of trustworthiness in a qualitative

study. Credibility refers to the believability of the data, confidence in the truth of the data and interpretation (Polit & Beck 2006). To establish credibility it´s important to have enough data, to choose the most appropriate method for data collection and by having interviewees with both gender and different ages it contributes to a richer variation of information in the study (Graneheim, Lundman 2003).When analyzing the data the researchers used Burnards’ (1991) method description of content analysis. According to Roberts P et al (2006) qualitative content analysis is a particularlyreliable method when it comes to handling data. Using content analysis when analyzing the interviews, specific codes are created to describe the data such as statements from the interview transcripts and can be confirmed by going back to previously coded data occasionally to check for stability over time. Credibility of research findings also deals with how well the categories cover data. This means that no relevant data have been accidentally or systematically excluded or that irrelevant data is included.The researchers handed the material over to Dr Rödöö, who read the material through and then they had a discussion about the analyzing process.By doing this the study’s trustworthiness was further increased (Polit & Beck, 2006).

Dependability refers to the stability of data over time and through certain conditions (Polit &

Beck 2006). In this study the researchers used the same interview guide during all the interviews to increase dependability of the results from the interviews. To increase

dependability the researchers used a stepwise replication. The researchers read through the transcripts data of the interviews and made marginal notes for coding. Codes were then compared and revised until agreement was reached. When the coding was completed the material was given to an external reviewer, Dr Rödöö, a colleague at the hospital. Dr Rödöö

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reviewed the entire set of transcribed interviews and validated the findings with the researchers.

Transferability refers to the extent to which the findings can be transferred to other settings or

groups. To make the transferability possible it is important to give a clear and individual description of culture, environment and surrounding, selection and characteristics of participants, data collection and process of analysis. A wide and rich presentation of the findings together with suitable quotations will also improve the transferability of the study (Graneheim, Lundman 2003).

In this study the informants were eight nurses, seven females and one male. They were between the ages of 23-57, working at the Mpongwe Mission Hospital, a rural hospital in the Copperbelt area of Zambia. They had all been working at the hospital for more than three months and had experience of working with HIV-prevention among women.

According to Malterud (2009) the researchers previous personal and professional experiences, pre-studies, motivations and beliefs about how things are, is going to affect what they choose to investigate, the method, the findings and the conclusions of the study. This is called

preconceptions. Malterud also mentions that preconceptions are not the same as bias if the researchers make sure to mention them in the report. In this study both researchers are nurse students and have knowledge about the HIV-infection, how it affects people and how to prevent it. Even if both researchers have knowledge about the disease either of them has worked with it, nor in Sweden or in other countries.

Analysis of the research data

According to Granskär and Höglund (2008) a qualitative content analysis focuses on the

interpretation of a text and is well suited to be used when studying health sciences. The gathered data was analyzed through Burnards (1991) method description of content analysis. By using this method the most important data is identified and the purpose of analyzing is to put together and structure the themes and issues that will be found during the interviews into different categories. Burnard (1991) describes the analysis process in 14 steps.

These steps includes making memos and notes after each session when the interview is still fresh in mind, reading through the transcripts and making notes on general themes and then making different headings to describe all aspects of the content. The headings will later be put together into broader categories to reduce the number of headings. To have an extern part to generate category systems without seeing the researchers list is also important to increase the validity of the study and to reduce researcher bias. Coding of the different headings, for example with different colors can be helpful when putting the headers together. Once the section is together the writing process begins (Burnard, 1991).

1. Notes are written after each interview and throughout the project memos are being written of how to categorize the data and also to keep the researchers thoughts and ideas fresh. 2. Transcripts are made and notes written on the general themes, this to be immersed in the data.

3. The transcripts are read through another time and headings made to describe all aspects of the content.

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4. Similar categories are put together in broader categories to reduce the number of categories. 5. The categories and sub-headings are being worked through to create the final list.

6. Two colleagues are independently making category lists which are compared with the researcher’s categories. The three lists are discussed and changes are if necessary made. This is to increase the validity and guard against bias.

7. Transcripts are read yet another time together with the final categories and subheadings to make sure everything is covered.

8. Each category receives a color and the transcripts are worked through together with the categories and subheadings and coded in its right color.

9. Data with the same color is cut out from the transcripts and put together under its category. 10. The cutouts are pasted on a paper under its category.

11. To check if the category system is correct the researchers might ask the respondents if the categories are matching their answers.

12. The sections are filed together and the original recordings are saved if it’s necessary to return to the original material.

13. The writing process begins. The researcher works with one section at a time and can always return to the original material if anything is unclear.

14. The researcher decides whether to link the data to the literature or not.

In this study the material from each interview was transcribed while the information was still fresh in mind. To keep the participation and information confidentially each of the participants were given a number. All transcripts were read through several times by both researchers and notes were made on the content. The text was being read through another time and codes and

subheadings were written to describe the content of the interviews. These different subheadings were divided into eight broader categories after their similarities. To reduce the number of categories, they were looked through once more and the researchers reduced the number of categories to five by putting three of them together.

To increase the study’s validity the data was given to Dr Rödöö, a physician from Sweden who was working at the Mpongwe Mission Hospital at the time the study was conducted. The data and the notes were read by Dr Rödöö but with no access to the list of subheadings and themes that already had been made. After reading the material the list of subheading were discussed between the researchers and Dr Rödöö and an agreement to keep the previous chosen categories were made. To make sure that all the relevant data was being covered by the categories, the transcripts were re-read along with the subheadings and categories. The five categories were given its own color and the text was coded with the different colors depending on which category it belonged to. Each colored section was cut out and was paste under the right color on an A3 paper. Through this method the researchers had a complete, grouped set of pages, containing all of the analyzed

transcripts. Since the material was read by the mentor and by colleagues, the researchers chose not to return to the participants with the material to increase validity.

The transcribed interviews and notes were saved on the computer and on two USB sticks. The original material was also saved so that the researchers could have the possibility to go back during the analyzing process if anything was unclear. When the categories were done the writing process began and the researchers chose to write it category by category. The original material was available during the whole process so the researchers could return to the original source if needed. The researchers chose to write the link between findings and literature in the discussion part of the study.

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Ethical considerations

The collected data and information from the interviews of the nurses were handled confidentially. Confidentiality in research means that the private data that identifies the individuals in the study is not going to be shown or reported. This could be information like name, personal id and identifying features (Kvale, 1997). To be able to maintain this

confidentiality when collecting the data from the interviews the researchers coded each interview with a number.

According to ”Forskningsetiska principerna” (Vetenskapsrådet, 1990) third main demand when conducting a study is that all the data that was collected from the informants have to be kept safe so that unauthorized can´t take part of the information. The researchers kept all the information and transcripts from the interviews , including tapes, notes, computers and a USB-stick with a back up locked in a room which only the researchers had access to.

The researchers made sure that the participants were informed that the study was for learning purpose only and that nobody was going to be criticized or questioned of how they performed their work, both verbally and by a written form.

When doing a research it should be practiced with concern about the ethical principles of goodness, autonomy and justice. The researcher should consider the eventual risks within the study in proportion to expected gain (Polit & Beck, 2006).

Information and approval

According to Polit & Beck (2006) it´s important to be in contact with a gatekeeper who can provide access to important sources of data and can make arrangements for gaining entrée. The director of the Mpongwe Mission Hospital Mr. Tuesday Musaka provided the researchers with a gatekeeper, Mirriam Kalenga. Mirriam who is a nurse at Mpongwe Mission Hospital informed the researchers that the most appropriate time to be introduced to the staff was during the morning meetings.

According to ”Forskningsetiska principerna” (Vetenskapsrådet, 1990) there are four different main demands when conducting a study:

• Informationskravet- Information about the aim of the study, voluntary participation and the right to stop participate at any time, must be given to the participants.

• Samtyckeskravet- The participants have full right to decide if they want to participate in the study or not.

• Konfidentialitetskravet- personal data about the participants have to be handled

confidentially and be kept safe so that unauthorized can´t take part of the information. • Nyttjandekravet- Data collected from the participants may be used only for research

purposes.

The nurses at the hospital were informed about the study during a morning meeting, both verbally and by a written form (Appendix 1) and also when the researchers visited the different wards. The information at the morning meeting included the aim of the study, the methods and the outcome of their participation in the study. The researchers also informed the nurses that attendance is voluntary and they could at any time stop participating in the

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study and that all the information would be handled confidentially. The nurses were informed that the research is for learning purpose only and it´s financed by SIDA through Malmö University.

The nurses were given time to ask questions about the study after the information at the morning meeting. The researchers contact information was also given to the nurses and they were told that if they had any further questions they shouldn´t hesitate to contact them. To get the nurses consent, they signed a paper of approval (Appendix 2) before the interviews started.

Ethical permission

The researchers have been given permission by Mr. Tuesday Musaka to implement the interview study at the Mpongwe Mission Hospital and by the local ethical rights to appeal at Health and society, Malmö University.

RESULT

The result from the interviews is presented below in five categories with subheadings about the nurses preventive-measures against HIV.

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Guidelines

Mpongwe Mission Hospital has guidelines in the HIV-prevention from the Ministry of health in Zambia and from CHAZ (Churches health association of Zambia). In the PMTC

department (Prevention mother to child) they have their own guidelines (2010 National protocols Guidelines, Integrated prevention of mother to child transmission of HIV), which are also provided by the Ministry of health. According to one of the nurses every ward has a book “An infection prevention manual for community and healthcare institutions in

developing countries” of how to prevent infectious diseases and the basic routines are put on

posters on each ward. Even though the hospital has these guidelines many of the nurses are unaware of them and one of the nurses says:

“In the hospital setup I think the most challenging part is, you find that most of the people, even though we have all these things like the books, the flyers given, you still find that even most of the healthworkers actually don’t have the knowledge that is given in the books, so I really wish that everyone could be in the position to be reading so that

everyone is safe.”

(interviewperson nr 5)

Although the hospital has guidelines many of the nurses are unaware of them and one of the nurses says:

“I don´t think so, I don´t think we have any guidelines. I have not seen any.”

Interventions to reduce the risk of HIV-infection

The nurses at the Mpongwe Mission Hospital have many methods and strategies in their work to prevent HIV among women. Explaining to the women the importance of how to prevent and how to protect themselves from this disease is something they have to deal with everyday. Since it´s a category containing much information it´s divided into three subheadings - information and education, contraceptives, testing and the importance of

nursing competence.

Information and education

Information and education is an important part of the prevention of HIV among women. To people who are in relationships the nurses are trying to explain the importance of being faithful and sticking to one partner. To younger females the nurses are trying really hard to encourage them to abstain from sexual relations and they are explaining to them why this is so important.

“The prevention that we are actually trying to teach/…/is the importance of abstinence. We always try and always want everyone to live and abstain from this unprotected sex, even if it’s protected we want them to abstain, that is the number one.”

(interviewperson nr 1)

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The hospital has a school health program and once a month they teach the pupils about infectious diseases and among them HIV. They teach in primary and secondary school about sexual activities, the importance of abstinence and then the children are given a quiz to make sure they’ve understood the information. The main groups they want to reach are the youths since they are most sexually active. Drama groups are also being used for the prevention of HIV. The show talks about the risk factors, what will happen when they get sick, how to prevent it and where to get help if the get sick. They are correcting the misunderstandings and tell them where they can be tested.

At the hospital information is also given as single-, couple- and group education. For example at the doctors clinic the nurses use the time when the patients are waiting for their

appointment with the doctor to counsel the patient about HIV-prevention, risk factors, where to get tested and how to get treatment if tested positive. During the counseling the nurse makes sure that the patients understand the information that they have been given.

“You also have to ensure that the patient understands what you are telling them, you ask them questions that will make them open up and you can confirm that they understood it and that they caught the right information.”

Contraceptives

The most common contraceptives used by the people in Mpongwe are condoms, p-pills and injectable contraceptives. The nurses are encouraging people to use condoms since it also prevents sexual transmitted diseases including HIV. Not using contraceptives has in the past been a part of tradition, people were afraid to ask for them but it has started to change. Now both male and females are coming to collect condoms at the hospital.

“We have seen that many people are afraid to ask for condoms. In the past it used to be very difficult most with ladies. /…/ It was very hard for them to tell their partner to use condom. But now we have seen a change even among the men.”

Even if the nurses want all people to use condoms to prevent both unwanted pregnancies and sexual transmitted diseases they always think the first alternative should be abstinence and/or being faithful.

Testing for HIV

In Zambia all pregnant women have to be tested for HIV to get their medical card, this is a way of preventing the unborn child from getting the infection. The women who are tested positive are given anti-retroviral drugs from week 14 and until they deliver their child. When the child is born it is also given drugs to prevent the infection to spread through the mothers’ breast milk. Having all the pregnant women tested for HIV gave the nurses an opportunity to encourage them to bring their husbands for testing. The hospital also has a policy from January 2011, to test all children being admitted to the children’s ward. If a patient is tested positive with HIV the nurses inform them that it´s important that their partner gets tested too. There are a few obstacles when it comes to testing for HIV, one of them is that people are ashamed to be HIV-positive and they keep it a secret from their partner and family. Another

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obstacle is that some believe that if they get tested positive they will die straight away and that prevents many from being tested.

“/…/so we make them understand that you do not die testing, it just opens a door for you to get help. You get medical help, you get tested, we counsel and tell you what you are supposed to do and what you are not supposed to do.”

To encourage men to come for voluntary HIV testing, the hospital shows their appreciation by giving the patients for example cooking oil, salt or sugar because many have a poor economy.

Importance of nursing competence

The nurses approach all patients with respect and good approach also means having their family and husband in mind when addressing them.

“You should always have in mind that they are humans like you that got their own fear, and it depends on you and how you take them. It can either help them or destroy them. So you should look at what their believes are and what they know about HIV and HIV prevention/…/you look at the age of the patient, the sex then you look at the background of that patient so you have in mind all those things when you are talking to them so it will be easier for them to open up and easier for you to reach their heart”

The nurses also have a responsibility to protect themselves by using protective clothing like gloves, gowns, aprons, disinfection of the floors and the instruments. These measures are to protect themselves from catching or/and spreading infectious diseases and among them the HIV-infection.

Reaching out to the people

Mpongwe district covers a large area and many of the people live too far away from the hospital and that makes it impossible for them to go to the hospital if they need medical attention. Therefore the Mpongwe Mission Hospital has organized different ways to reach out to those.

Healthcommunities

Each community has healthworkers who have been educated by people from the hospital. The education includes teaching the people in the village about HIV, how to prevent the disease, how to be tested and also how to get treatment. They are responsible to look after the patients in the community. If a patient doesn’t come to the hospital when they have an appointment, the hospital contacts the healthworkers and they must find the patient and find out why he or she missed the appointment. The healthcommunity receives a schedule from the hospital of which day nurses will arrive to the community and the healthworkers have to make sure all the people in the village are being gathered.

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The communities also have HIV adherence supporters who make sure that the people who are HIV-positive are taking their drugs. If the patients aren’t taking the medication as they

should, they have to go to the hospital.

Outreach

The hospital has outreach once a week which means that one nurse is going out to five different parts of the community far away from the hospital to encourage people to take part in health, give them healtheducation and also do a follow-up on discharged patients. If someone’s very ill, that person is being admitted to the hospital. On the outreach the women who are pregnant will be examined and told to come to the hospital for obligational HIV-testing. Outreach is the only possibility to reach out to those people and inform the women of the HIV infection, what it means if you get sick and how to prevent themselves.

“We go out for outreach in different parts of the community, some they don´t have access to come to the hospital. We go to the different places to teach them about how they prevent themselves from being infected with HIV. Then for example the ones who are pregnant we teach them.”

(inteviewperson nr 5)

Obstacles and challenges

The nurses at the Mpongwe Mission Hospital are working daily to spread the right

information about infectious diseases and trying to get the people to change their behaviors in the hope of lowering the morbidity of HIV. Even though they are working continuously with their preventionwork, they face many obstacles and challenges each day.

Misconceptions

One of the challenges the nurses are facing is that many people have the wrong information about HIV and how to prevent it and to change their mentality is not very easy.

“You counsel them, you give them information and they seem to understand but once they go back home it´s something different. They go back to the old things they believed and forget about the things you taught them.”

Many people are illiterate and don’t understand the information they are being given and why they have to change their lifestyle.

“it’s just the illiteracy, themselves the people, you tell them to do this, to do the right thing, but they will not listen to you, usually they do the opposite thing”

Unfortunately some men believe that if they are infected with HIV, they will get cured by having sex with a very young girl. The family to the girl that has been raped is often so ashamed that they keep quiet and don’t give her the medical attention that she needs. The girl has then an infection in her body that isn’t being treated.

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“/…/if you are a man and are HIV positive and have sex with a very young girl you get cured is really an obstacle/…/the family prefer to keep quiet about it because they are so ashamed about what has happened to their little girl so they prefer no one knows about it”

Another challenge for the nurses is that people still believe in witchcraft and herbalists. They rather go to the herbalist for treatment instead of going to the hospital for proper treatment. People who believe in witchcraft think the HIV infection’s their destiny because of something they’ve done and won’t accept any treatment except from a witchdoctor.

Some people that are being tested positive for HIV don’t feel sick and keep living their life like they always have. They don’t understand they have to change their lifestyle and get treatment. They don’t tell their partner or family which means that they don’t prevent the virus from being spread to others.

“/…/when people are infected and are positive with HIV they are not yet sick, they feel healthy and continue working/…/some don’t tell the man they are marrying that they’re HIV positive/…/they continue hiding that they are positive so they keep on infecting other people in that way”

“some of the women have a hard time to understand the information we are giving them, that’s why we are giving them healtheducation so that they get the knowledge how the virus is spreading”

Stigma

People are afraid to be judged and many keep their diagnose to themselves. No one wants others to know if they are HIV-positive or not because they feel it´s a disgrace to be positive and they won’t blend in anymore.

“I think it’s stigma. Maybe they are afraid they going to be criticized especially people who are married, it’s very rare for them to come and have condoms for preventions and then even the stigma in general even the boys they feel their guilt”

Early marriage and pregnancy

It´s very common that girls are getting married in an early age, some even at 13 years of age and they often get married to a man who is much older than they are. This is partly because of the tradition in Zambia and partly because the girls has no other way to provide for

themselves because in some cases they have lost their parents. Early marriage is according to the nurses at the hospital one of the problems when it comes to the prevention of HIV among women. With an early marriage comes an early sexual debut. Due to the age difference the men have often sexual experience and there is a risk that he´s been infected and then will infect his young wife with HIV. Marrying at this young age often means that they girls will

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have their first pregnancy at a very young age and there is always a risk of passing the infection to the unborn child.

“They normally get married at 13 and they´ve got kids at 13. I think it´s the common one”

“Sometimes it is difficult for the patients to listen to us. /…/ There are girls who are getting married at 13 years of age and gets pregnant and when you test them they are HIV positive. So the problem is, how can we convince them?!”

According to the tradition in Zambia, a woman don´t tell anyone about her pregnancy in an early stage. This creates a problem due to the Zambian guidelines from the Ministry of Health, which says that every pregnant woman should be tested for HIV in the 14th week of the pregnancy. By testing this early the hospital gets a chance to catch those mothers who are positive and then be able to put them on Anti Retro viral Treatment (ART) so that the risk of passing the virus to the unborn child is as small as possible. With women hiding their

pregnancy and don´t get tested, they miss the opportunity for ART and their children are born with HIV.

“I think some of the challenges that we have here is that the women doesn´t come as early as we want so that they could be put on treatment. Mothers can sometimes come just before the delivery”

Poor financing

Because of the poor economy at the Hospital they can´t afford to hire the staff that they need and one nurse has to do a workload that was meant for three nurses. This leads to patients not always getting the care, information and the support that they need because the nurse just doesn´t have the time. The lack of nurses also means that they don´t have enough time that they would like, going out to schools to inform and educate pupils about HIV-prevention and to send nurses on outreach.

“Sometimes you are not doing all the necessary things you are supposed to be doing, there is to much work. You find that you are alone and you have to see this woman, her baby, her husband and you have to give the right information to them.”

The Mpongwe Mission Hospital is a rural hospital and the admitted patients aren’t paying anything for their treatment. According to the nurses they are understaffed and they don’t have enough vehicles for transport or medical supplies due to a poor economy. The hospital has two vehicles, one ambulance and one landcruiser and that’s not enough considering all the places they have to reach out to. One other problem is also that the gas for the vehicles is so expensive and cost a lot of money for the hospital.

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“going to these far places it’s quite challenging/…/we have our ambulance and the landcruiser/…/and it’s making work slightly difficult because we are needed in so many places”

Progress

The interviews show that progress in HIV-prevention at Mpongwe Mission Hospital is being made but there is still things that can be improved.

Small steps ahead

Even if HIV still is a great problem in Zambia, the nurses at the Mpongwe Mission Hospital have seen an improvement of women wanting to know how to prevent themselves by coming for testing of HIV and also by the numbers of HIV-infected. The increasing number of women getting tested for HIV is a confirmation of their work is paying off. That the nurses are able to reach out to the women and the women understand the information they are given about the prevention.

“I think the work in the community and advising the women about the disease is giving a better result. Information is really important”

The nurses have also noticed that women are more open-minded when it comes to talking about the HIV-infection than they used to. One nurse describes how they have noticed a positive change in the prevention work like this:

“It´s successful because a lot of women are coming to maternity to be tested, and we feel that people are opening up, even those who are HIV-positive. People can see that HIV is real and that something can be done. They don´t loose hope and have started to learn that they are putting themselves at risks when they don´t open up about the disease.”

The use of condoms is also something that has been improving the last couple of years. The nurses are noticing that more and more people are coming to collect condoms and they think it´s because the tradition is changing. Another large improvement in the HIV-prevention work among women is that men are now also coming to collect the condoms for protection.

“The tradition is they don’t like the use of condoms. But now we have seen a change and most of them come, even the boys will come. In the past no one came to collect the condoms, but now they come and that is good”

When it comes to prevent pregnant women of passing the infection on to their unborn child, the guidelines “prevention of mother to child transmission” that were launched 1999 by the ministry of health in Zambia made a large different. Nowadays pregnant women have to be tested and it has been a large improvement in the prevention work of HIV when they are able to prevent the transmission from mother to child in an early stage.

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“Before the women would only come for voluntary consultation. But now when women are pregnant they have to be tested, weather they like it or not and that has been

successful. Ofcourse you don´t just test them, they will come one and one and you teach them about HIV and have a discussion with them. This is everywhere in the country and where ever you go this is the policy for all the hospitals.”

What could make the HIV-preventionwork at Mpongwe Mission Hospital better?

The nurses at the hospital have many ideas and thoughts of how to make the prevention work better, and their all about money. They talk about people’s financial status, especially children who loose their parents at an early age and then can’t provide for themselves. This leads to that some children can’t stay in school since they can’t pay their school fee. Instead they go to the market and expose themselves to things children aren’t supposed to be exposed to at such a young age. They might sell maize or work in bars or even sell themselves to get money so they can eat. If they could help those children so they can stay in school and get educated, they will know that prostitution isn’t the best way to earn money which means it a way to prevent HIV spreading.

“One of the contributing factors to people having HIV/Aids is their poor financial status/…/if they loose their parents/…/they can’t take care of themselves, they have no money and can’t continue school. Also they are living their life very risky, they start working at the market, go selling maize, they work in the bars because they need money for them to eat/…/If we have programs that can teach them skills like tailoring or other businessthings they don’t put themselves at risk of catching HIV.”

They also need to hire more nurses so they could have the time to sit down and talk to the women and learn what they know about HIV and how to prevent it. To get the men more involved together with their wives or girlfriends and make them come to the counseling so that they both have the same knowledge of how to prevent HIV.

“/…/to also educate the couple. The men should be more involved in the HIV prevention

so that they can understand the prevention.” (interviewperson nr 6)

“We try by all means to reach out to them, but what I would love is/…/I feel like if we had

a lot of nurses here at the hospital it would be better/…/I think that one will be so successful ”

People need more information and education about how to prevent HIV both in school and on other sites too. To involve people, young and old so they can spread the information about the disease and how it can be prevented.

“I think we have to inform every other person. Even the males and in the community and

maybe if we have time we could go out and teach in schools and get the pupils to involve themselves/…/teaching in the community so that at least we’ll be able to help eachother ”

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If a patient comes to Mpongwe Mission Hospital she has to go through the outpatients

department where she will be seen by a doctor. If that patient would like to get tested for HIV she has to go through the counseling department which means that she will loose her spot in the cue to see the doctor. Because of that many patients choose not to get HIV-tested. To make the HIV-testing easier and more convenient for patients, the nurses at Mpongwe Mission Hospital would like to be able to test for HIV in the outpatients department and not just at the counseling department. By this they are hoping that more people choose to get tested.

“We are hoping that in the future we can also do the testing in the outpatientsdepartment because now they have to go to the counsellingdepartment and that is not good because they move out of the outpatientline. Someone will take their place so that they are delayed to get the services that they need. So we are hoping that if we can start the testing in the outpatientdepartment we can test them right there and then.”

DISCUSSION

In this part the researchers discuss the results of the study and the method being used.

Result discussion

When discussing the results of the study the researchers have chosen to discuss each heading separately. In the discussion the results from the interviews with the nurses will be compared with literature and medical articles concerning HIV-prevention.

Guidelines

In Zambia all the hospitals are provided with guidelines from the Ministry of health in Zambia and from CHAZ (Churches Health Association of Zambia), of how to prevent HIV and other infectious diseases. These guidelines are available on all the wards at Mpongwe Mission Hospital and according to one of the informants in the study all the employees are suppose to know about them. The most important of the guidelines are also written on posters, hanging on the walls at some of the wards. Even though the guidelines should be well known among the employees, some of the nurses did not know of the guidelines and where they could find them. During the researchers time at the hospital they got the impression that the nurses´ didn´t have the time to reflect on their work, if they worked according to the

guidelines, if changes could be made to improve their prevention work and if the patients understood them when they tried to teach them about HIV. A study from Atlanta in USA (Bluespruce et al, 2001) shows that lack of time among the nurses and other medical issues were the key barriers to talking with “at-risk” patients about HIV prevention rather then patients discomfort discussing sexual behaviours.

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Starting in January 2011 all pregnant women have to be tested for HIV in Zambia and at the maternity ward at the Mpongwe Mission Hospital they have special guidelines concerning mother to child prevention. On this ward all of the nurses in the study were aware of the guidelines concerning HIV-prevention and it seemed like the nurses was working very hard to make all the pregnant women to come and test themselves for HIV. If the enthusiasm about having patients tested for HIV and working according to the guidelines would be as strong at the rest of the hospital maybe more people would get tested and the knowledge of how to prevent HIV would be improved among the staff. Knowledge gaps due to insufficient education and training capacity affects the nurses’ performance. The lack of adequate

teachers, research capacity and training that’s outdated might leave the nurses unprepared and without the right knowledge (Lule et al, 2009).

Measures to reduce the risk of HIV-infections

The respondents at Mpongwe Mission Hospital are aware of the problem that HIV is causing and they have several methods and strategies trying to prevent the infection among women. One of these strategies is to give information to the society about how the HIV-infection, what it is and what to do. According to Egerö et al (2001) the most important in the work to prevent HIV is to increase the knowledge of HIV/AIDS and to make people understand the risks, how the disease spreads and different ways to prevent it. Students and young women are two of the groups that the hospital work hard to get the information through to. This is the time when they are getting sexual active and it´s important that they have knowledge about HIV according to the nurses.

In 2002 the three main churches in Zambia passed a resolution endorsing condom use for preventing HIV between married couples but in all other cases they encourage abstinence only (www.avert.org). According to the nurses this is the right approach and they explain that the most important thing to teach the young people is abstinence. A study from 2010 has shown that there has been a significant reduction in the proportion of 15 to19-year old women and men with early sexual debut in Zambia. Among women the numbers have gone from 19.4 % in 1992 to 12.3 % in 2007 (Ghys et al, 2010). These results could be an indication that the information is reaching out to the young people and that the prevention work is successful. Even though this is a good result everyone doesn´t think this is the best approach. According to the AIDS experts this is an ineffective approach and they want all the churches to

encourage condom use for everyone, and not just for the married couples (www.avert.org). The researchers think that it would be even more effective to teach the young people in schools the importance of using condoms both as a contraceptive and as way to prevent HIV. It´s a challenge getting them to abstain from sexual activities and therefore the researchers believe that it would be more effective to also teach them safe sex.

In Mpongwe the most common contraceptives used by the people are condoms, birth control pills and injectable contraceptives. The nurses interviewed are also seeing a positive change in the use of these contraceptives. Just a few years ago people were afraid to ask for condoms and according to the tradition people shouldn´t use contraceptives. Today both men and women are coming to collect condoms at the hospital and many of the couples are using family planning. Even if the nurses in this study are noticing a positive change in the use of contraceptives there are still cultural beliefs and traditions that are causing obstacles when it comes to safe sex and preventing unwanted pregnancies. Research made 2010 in Zambia concerning knowledge and use of modern family planning shows that the main reasons for

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non use of contraceptive methods were religious beliefs (50%), partner disapproval (30%) and side effects (20%) (Mubita- Ngoma C, 2010).

In this study the researchers believe that it is hard to overcome the religious beliefs but if the nurses would involve the men more when it comes to family planning more women would know about and use contraceptives.

In Zambia all pregnant women have to be tested for HIV and this has been a success according to the nurses interviewed in this study at Mpongwe Mission Hospital when it comes to prevent mother to child transmission of HIV. But a problem is still to get the rest of the population to come for voluntary testing. The nurses are experiencing that many people are choosing not to get tested because of that they are afraid of the results. According to the nurses people have the belief that if they test positive they will die straight away. During the time the researchers spent at the hospital they got the impression that the nurses have to put a lot of effort in correcting misunderstandings about HIV. The researchers believe that the only way to get more people tested for HIV is to continue to educate people and correcting

misconceptions and give facts about why it´s so important to get tested.

Reaching out to the people

Many of the hospitals in Zambia including Mpongwe Mission Hospital cover a great area with a large population which makes it hard to provide healthcare for everyone. Mpongwe district is widely spread and many of the people live far away from the hospital. They have no opportunity to come for check ups, to get information and other medical care. To be able to reach out to all these people Mpongwe Mission Hospital has health communities who they are cooperating with. The health communities cover these areas and each community has a health worker who has responsibility of looking after the people in the community and has contact with the hospital. The health workers are educated by the hospital and it includes teaching people in the community about HIV, hygiene issues and how to they can prevent themselves from catching other diseases. According to the nurses in the study, health workers are an effective tool to get the information out to people even if they live in the most rural part of Africa. Everybody deserves to know how to take care of themselves and how to prevent themselves from diseases and among them the HIV-infection.

Mpongwe Mission Hospital has four different health communities. The nurses go to one community each week for checkups on the pregnant women and their children. In this study the researchers got the opportunity to come along on one outreach. The nurses examined the pregnant women, gave the kids vaccinations and weighed them, to mention a few things. They did a great job working all day with all those people who had come a long way for their check-up. This could also be a great opportunity to gather women, also those who weren´t pregnant and men to give them information or just talk to them on how they protect

themselves against HIV, if they use condoms or if the have any questions about the disease. Maybe the nurses felt as though they didn´t have the time but the researchers believe that they are missing good opportunity of working with HIV-prevention on their outreach.

According to avert.org (2010-10-13) peoples’ knowledge is still very poor concerning HIV. In 2007 almost two thirds of the 15-24 year olds could not correctly identify ways of

protecting sexual transmission of HIV. Therefore it´s important to take every opportunity the nurses have to teach people about the disease.