Degree Project in nursing Malmö University
61-90 hp Faculty of Health and Society
Nursing program 205 06 Malmö
June 2019
REGISTERED NURSES’ EXPERIENCES
OF COUNSELING YOUNG ADULTS
ABOUT HIV
A MINOR FIELD STUDY AT LUBAGA HOSPITAL,
KAMPALA, UGANDA
CARL GREEN
WICTORIA TREI
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REGISTERED NURSES’ EXPERIENCES
OF COUNSELING YOUNG ADULTS
ABOUT HIV
A MINOR FIELD STUDY AT LUBAGA HOSPITAL,
KAMPALA, UGANDA
CARL GREEN
WICTORIA TREI
Green, C & Trei, W. Registered nurses’ experiences of counseling young adults about HIV. A Minor Field Study at Lubaga Hospital, Kampala, Uganda. Degree Project in nursing 15 credit
points, Malmö University: Faculty of Health and Society, Department of Care Science, 2019. Background: In the early 1990’s Uganda suffered from a HIV-epidemic and was one of the
most effected countries in Sub-Sahara Africa. However, from 1990 - 2010, the level of HIV-infected people dropped from 18 to 6 % due to awareness raising and less high-risk behaviors such as unsafe sex. Today, Uganda has one of the highest levels of newly infected people. Young adults in the ages 15 - 24 years old are the most exposed group to get infected with HIV in Uganda. Counseling is a common task in nursing all around the world. Although the specifics of how counseling is performed could differ, the main goal is to reduce the number of high-risk behaviors and motivate the person to engage in safe sex, including sexual contact and use of condoms.
Aim: The purpose of this study is to describe nurses’ experiences of counseling young adults
about HIV.
Method: A qualitative study with semi-structured interviews at Lubaga hospital in Kampala,
Uganda. 12 registered nurses were interviewed from three wards at the hospital, the material was transcript and then analyzed with an inductive qualitative content analysis approach inspired by Burnard.
Results: Four themes were identified: a complex environment to counsel young adults in,
young adult’s efforts to self-care, socio-economic challenges linked to HIV and young adult’s feelings associated with HIV. Moreover, 11 categories emerged through the themes.
Conclusion: Registered nurses experience both factors that burdens and facilitate counseling.
In conclusion, young adults fear of HIV, HIV-related stigma and socioeconomic factors pose an obstacle when counseling young adults about HIV and young adults’ resources makes counseling easier.
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SJUKSKÖTERSKORS ERFARENHET
AV ATT HA RÅDGIVANDE SAMTAL
MED UNGA VUXNA OM HIV
EN MINOR FIELD STUDY PÅ LUBAGA SJUKHUS I
KAMPALA, UGANDA
CARL GREEN
WICTORIA TREI
Green, C & Trei, W. Sjuksköterskors erfarenhet av att ha rådgivande samtal med unga vuxna om HIV. En Minor Field Study på Lubaga Sjukhus i Kampala, Uganda. Examensarbete i
omvårdnad 15 högskolepoäng. Malmö Universitet: Fakulteten för Hälsa och samhälle,
Institutionen för vårdvetenskap, 2019.
Bakgrund: Under tidigt 1990-tal drabbades Uganda av en HIV epidemi och var ett av de
hårdast drabbade länderna söder om Sahara. Mellan 1990 - 2010, sjönk antalet Hivinfekterade personer från 18 till 6 %, till följd av ökad medvetenhet och mer säkert sex. Idag har Uganda en av de högsta nivåerna av nyligen infekterade människor. Unga vuxna i åldrarna 15–24 år är den grupp med högst risk att bli infekterade med HIV i Uganda. Det är vanligt att
sjuksköterskor runt om i världen har rådgivande samtal. Även om hur rådgivning utförs kan variera så är målet att minska riskbeteenden och motivera till att ha säkert sex.
Syfte: Syftet med den här kandidatuppsatsen är att beskriva legitimerade sjuksköterskors
erfarenheter av att ha rådgivande samtal med unga vuxna om HIV.
Metod: En kvalitativ studie med semistrukturerade intervjuer på Lubaga sjukhus i Kampala,
Uganda. 12 legitimerade sjuksköterskor intervjuades från tre olika avdelningar, materialet transkriberades och analyserades med en induktiv kvalitativ analysmetod, inspirerat av Burnard.
Resultat: Fyra teman identifierades: en komplex miljö att ha rådgivande samtal med unga
vuxna, unga vuxnas försök till självhjälp, Socioekonomisk utsatthet kopplat till HIV och unga vuxnas känslor relaterat till HIV. Ur dessa fyra teman upptäcktes 11 kategorier.
Konklusion: Legitimerade sjuksköterskor upplever att det finns både hjälpande och stjälpande
faktorer som påverkar deras rådgivande Sammanfattningsvis så orsakar unga vuxnas rädsla för HIV, stigma relaterat till HIV och socioekonomiska förhållanden hindrar för samtal och hur resursfulla unga vuxna är underlättar för rådgivande samtal.
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ACRONYMS
ABC Abstain, be faithful and condom use AIDS Acquired Immunodeficiency Syndrome ART Antiretroviral Therapy
HIV Human Immunodeficiency Virus PLWH People Living with HIV
PrEP Pre-exposure Prophylaxis
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TABLE OF CONTENT
ACRONYMS 3
INTRODUCTION 6
BACKGROUND 6
National work to treat and prevent the spread of HIV 6
Nurses’ work with HIV 7
PROBLEM DEFINITION 9
AIM 9
METHOD 9
Data collection and storage of data 10
Data analysis 12
Ethical considerations 12
RESULTS 13
Young adults' feelings associated with HIV 13
Young adult’s fear 14
A feeling to be alienated 14
Feelings of anger 14
Socio-economic challenges linked to HIV 15
HIV-related Stigmatization 15
Economic dependency 15
Living in poor accommodation 15
A complex environment to counsel young adults in 16
Young adult’s Behavior 16
Information about HIV 16
Young adult’s efforts to self-care 17
Prevention to limit the spread of HIV 17
Young adult’s adherence 18
Transmission routes of HIV 18
DISCUSSION 18
Discussion of method 18
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Result discussion 20
Discussion about fear of the healthcare system 20
Discussion about stigmatization in the society 21
Discussion about young adult's behavior and information about HIV 21
Discussion about prevention to limit the spread of HIV 21
CONCLUSION 22
SUGGESTION FOR DEVELOPMENT AND QUALITY IMPROVEMENT 23
REFERENCES 24 APPENDIX 1 28 APPENDIX 2 29 APPENDIX 3 30 APPENDIX 4 31 APPENDIX 5 32
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INTRODUCTION
In the early 1990’s Uganda suffered a Human immunodeficiency virus epidemic and was one of the most affected countries in Sub-Sahara Africa (Sida 2018). However, during a 20-year period, from 1990 - 2010, the level of HIV-infected people dropped from 18 to 6 % due to awareness raising and more safe sex (Uganda AIDS Commission 2015) Today, Uganda has one of the highest levels of newly infected people every year with an estimated 52 000
incidents/year (UNAIDS 2017). Additionally, recent data shows that once again the spread of HIV is increasing and the knowledge about HIV is decreasing (Sida 2018). According to Uganda AIDS Commission (2015) the registered nurses work is essential to nurse for people living with HIV: Firstly, counseling to education are limiting high-risk behaviors such as unprotected sex (Zajac et al. 2015). Secondly, Relf (2013) points out the importance of registered nurses to support patients and act as their advocate. Lastly, according to Ridgeway (2018) nursing is improving HIV-positive people’s adherence. In order to make registered nurses’ counseling more accessible and to improve the quality of counseling it is essential to study registered nurses’ experiences of counseling young adults about HIV. The motivation for this thesis is our interest in nursing and internationalization.
BACKGROUND
Human immunodeficiency virus (HIV) is a retrovirus which weakens and destroys the host body’s immune system by gradually infecting the cells (Bott 2005). This causes a
degenerative immune deficiency which inhibits the body to fight off opportunistic infections and malignancies. Eventually (AIDS) Acquired Immunodeficiency Syndrome is developed through the HIV-infection. People with AIDS are often found to have opportunistic infections and malignancies due to a weakened immune system (ibid.). HIV can be spread through sexual contact and during childbirth (ibid; Lazarus et al. 2010). To this day there is no curing treatment, only maintenance therapy, antiretroviral therapy, (ART) (Bott 2005). ART reduces HIV in plasma and improves the survival rates. Moreover, is also reduces the risk of
spreading HIV. However, an important part of HIV-care is prevention and to reduce the spread of HIV (ibid.). The (ABC)-method, abstain, be faithful and condom use, to prevent transmission of HIV has been used in the general population in Uganda since the 1980s century (Murphy et al. 2006). Furthermore, pre-exposure prophylaxis (PrEP) may be used to prevent the spread of HIV within vulnerable populations (Campos-Outcalt 2018).
National work to treat and prevent the spread of HIV
Young adults in the ages 15 to 24 years old are the most exposed group to get infected with HIV in Uganda (Uganda AIDS Commission 2015). Although the level of mortality is decreasing due to higher level of access and adequate treatments, the frequency of HIV infections is significantly higher among young adults in the most vulnerable group compared to the general population. The higher frequency for this group is correlated to a higher degree of risk behavior, such as an early sex debut, multiple sex partners and unprotected sexual intercourse (ibid.). The Swedish International Development Cooperation Agency (Sida) (2018) finds that the knowledge of HIV is decreasing and the spread is increasing within young adults, in Uganda. Additionally, Uganda, Nigeria and South Africa represents 48 % of all the newly infected people in Sub-Sahara Africa (UNAIDS 2014). According to the Uganda AIDS Commission (2015) the HIV-epidemic is driven by behavioral, biomedical and
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factors includes: early sex-debut, multiple sex-partners and unsafe sex. Secondly, not enough people have access to ART-treatment, PrEP and HIV-testing. Lastly, gender-based violence may increase the risk of women getting HIV, decrease their adherence and deteriorating treatment outcome (ibid.).
In 2011 Uganda took on the challenge to eliminate the spread of HIV, to erase HIV-related discrimination and to prevent AIDS-related deaths by 2030 (Uganda AIDS Commission 2015). Additionally, Uganda also works towards the 90-90-90 target, prolonging to 2020. Firstly, 90 % of all people living with HIV (PLWH) will know their status. Secondly, 90 % of all people with a diagnosed HIV will receive ART-treatment. Finally, 90 % of all PLWH who are under treatment will reach viral suppression by 2020 (ibid.). To end the AIDS-epidemic by 2030 is a sub-goal to one of the United Nations’ Sustainable Development Goals, to ensure
a good health and promoting the well-being (Sustainable Development Goals Knowledge
platform 2018). UN, the member states and Non-Governmental Organizations strives to make health-care more accessible, educating key populations in disease transmission routes and safe sex (United Nations 2015). The Uganda AIDS Commission (2015) developed a national strategic plan to guide different sectors in Uganda to end the HIV and AIDS-epidemic. It was developed in 2011 and the latest version extend to 2020. Moreover, the national strategic plan propose actions towards four different areas: Care and treatment, Social support and
protections, system strengthening and Prevention. Conclusively to reach the sustainable development goal Good Health and wellbeing, with no new HIV-infections, to eliminate AIDS-related mortality and morbidity and HIV-related discrimination. Registered Nurses responsible to refill ART-medication for PLWH with good adherence and for streamline nurse driven care such as counseling to prevent the spread of HIV (ibid.).
Nurse’s work with HIV
Registered nurses have an obligation to promote health and prevent illness through nursing and education (International Council of Nurses 2012; Uganda Nurses and Midwives council 2018). Counseling is a common task in nursing all around the world (International Council of Nurses 2012). Although the specifics of how counseling is performed could differ, the main goal is to reduce the number of high-risk behaviors and motivate the person to engage in safe sex, including sexual contact and use of condoms (Zajac et al. 2015). Counseling is often performed face to face, but it can also be done with electronic messages or as group education (Camp et al. 2013). Nurses are independently planning and evaluating counseling to improve the quality of nursing and their own work (Svensk Sjuksköterskeförening 2017; WHO 2003). According to the International AIDS Society (2018) the results of nurse’s counseling is improved if the person is meeting the same nurse each time and establishes a good
relationship with the nurse. The effect of counseling is enhanced if the counseling period is prolonged (Camp et al. 2013). Through counseling Ugandan nurses are gathering information in order to get a holistic view of the person (Ministry of Health 2016). In cases of
unsuppressed viral loads, nurses identify and try to understand the causes for non-adherence. They ask the person about their socioeconomic status, sexuality, any drug-use and signs of depression, furthermore nurses find solutions to lower the viral load and to improve adherence (ibid.).
Self-efficacy-theory is a theory often used when caring for people with chronic diseases in educational purposes (Jiang et al. 2019). Self-efficacy is an individual’s belief in their own ability to achieve a set goal or to manage a certain task (Bandura 1997; 2008). This belief is affected by four modes: enactive mastery experience, vicarious experience, verbal persuasion and physiological and affective states. Enactive mastery experiences are about how, on the
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one hand, successful experiences builds a strong personal efficacy and on the other hand, how failure undermines it. Watching and observing other people can play an important role to learn, this is called vicarious experiences. By convincing oneself that they can complete a task or what Bandura calls, positive verbal persuasion, the person’s self-efficacy increases. In the last mode, physiological and affective states, people evaluate their ability to succeed from to their physiological and emotional states. If a person is trying to complete a task when they are feeling stressed, uncertain and worried, it is unlikely that the person has the efficacy to
overcome the task (ibid.; ibid.). The combined measure of the four modes determines how successful an educational intervention will be (Jiang et al. 2019).
Depression is common within PLWH (Rubin & Maki 2019), as a result of the initial crisis reaction but also by the distress of living with HIV (Grov et al. 2010). Furthermore, the stigma of being HIV positive and the side effects of ART-treatment is believed to cause depression (ibid.). Rubin and Maki (2019) and Ruiz-Perez (2017) also argues that there is a correlation between socioeconomic and psychosocial risk factors and depression within HIV-positive patients. If PLWH get depressed, Cha (2008) argues that their adherence may be negatively affected as a result of their confidence to comply with the care are low. According to Relf (2013), registered nurses have a comprehensive and a wide-ranging role while nursing for PLWH and depression. Depending on the nurse’s qualifications and level of education, they may act as the person’s advocate, counselor to educate people or carrying out
psychotherapy such as cognitive behavior therapy. Nurse’s counseling could be used to engage PLWH and depression in their own care but also to change certain behaviors. Nurses’ use evidenced practice and nursing improves the person’s wellbeing and their adherence (ibid.).
According to the World Health Organization (2003) and Ridgeway (2018) registered nurse’s counseling is effective to improve PLWH’s adherence. However, Ridgeway (ibid.) identifies a need to further explore effective interventions of HIV-positive young adult’s adherence in Sub-Sahara. Adherence is defined as:
“to the extent to which a person’s behavior - taking medication, following a diet, and/or executing lifestyle changes, corresponds with agreed recommendations from health-care providers.” (WHO 2003, page, 17).
To improve adherence, nursing should be person centered and registered nurses can act compassionate, be a practical and an emotional support to the person and their relatives (Harrowing 2011). On the other side, Harrowing (ibid.) points out the risk of compassion fatigue within Ugandan registered nurses due to heavy workload and lack of resources, such as few nurses per capita and stock outs due to empty stocks. By educating PLWH of the correlation between poor adherence and the risk of HIV evolving resistant toward ART, adherence improves (WHO 2003). Lastly, to increase their adherence, HIV-positive patients should feel comfortable to take the medication in front of other people, as a result nurses must work to reducing HIV-related stigma (ibid.). O’Malley (2019) argues a small decrease of self-stigmatization within PLWH and stigma in society towards ART-treatment and PrEP,
resulting in an increase adherence.
Goffman (1963) define stigmatization as how a society is viewing and judging a person because of certain characteristics they may have. Mprah (2016) however separates stigmatization into internal and external stigma. Firstly, internal stigma is how a person relates to their own self-image and self-worth. Secondly external stigma is how society is
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viewing a person with non-normative traits, discriminatory laws and acts in institutional settings and/or in the community. HIV-related stigma may cause PLWH to become isolated, lose their status and low adherence because of them hiding their ART-medication and not wanting to be seen visiting healthcare facilities (ibid.). With a greater social support PLWH have better adherence, their quality of life improves and the level of mental illness declines (Geary et al. 2014). Men are more likely to be open to their partner about their HIV-status and have less internal stigma. Little internalized stigma results in more sexual risk behaviors but also better perception of health due to a higher self-esteem (ibid.). However, according to Tam (2011), it is important to implement and improve counseling, to empower PLWH’s abilities to deal with the stigma. Women fear abandonment and domestic violence which results in internal stigma.
PROBLEM DEFINITION
Even with a global and a national strategy to reduce new infections, HIV-related stigma is present, and people die in AIDS. The spread of HIV is increasing and the knowledge of HIV is decreasing among young adults in Uganda. Nurses have a multifunctional role: to counsel young adults into behavior change, to be an emotional and a practical support and charging for refilling ART-medication. However, heavy workload and stock outs prevent Ugandan nurses to nurse. Furthermore, HIV-positive men and women do face stigmatization but not to the same degree and effective interventions to enhance young adult’s adherence have not yet been identified. It is important to develop efficient interventions to reduce HIV-related stigmatization, decrease the level of mental illness and to enhance adherence. To study
registered nurses’ experiences of counseling young adults is important in order to improve the quality and nurses’ possibilities to engage in counseling. The focus in this thesis is the nurse’s experiences of counseling and to take part of their knowledge within this area.
AIM
The purpose of this study is to describe nurses’ experiences of counseling young adults about HIV.
METHOD
Semi-structured interviews were used as method. 12 informants from three different units from Lubaga Hospital in Kampala were recruited by asking for potential attendees to participate. According to Polit and Beck (2014), convenience sampling is used to make participants to come forward and volunteer on their own. The public health is a clinic which provides several services such as HIV-testing, counseling and health-education at the hospital and in the community. At the internal medical ward, they care for patients with HIV, HIV and AIDS-related diseases. At the outpatient department PLWH that do not need to be
hospitalized are being cared for. Lubaga is a Catholic hospital and their mission is:
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quality and affordable health care services without discrimination, especially against the less privileged” (Lubaga Hospital 2018, About Us)
The registered nurses at Lubaga Hospital were rotating between the wards every two years, as a result nurses from different wards could be interviewed because they had recently been working with HIV.
Data collection and storage of data
Representatives from the three units were provided with written and verbal information by the examiners to spread to all the nurses that fulfilled the inclusion criteria:
To be a registered nurse.
Working with or recently had been working within HIV care.
To speak English.
Over 21 years old. Nurses younger than 21 years old could not been expected to have had finished an academic nursing program.
During the following week the examiners returned and asked potential participants to be interviewed, the registered nurses could then decide when and where the interviews would take place. Before every interview the informant read through the information letter once again (Appendix 2) and had the option to ask questions. All registered nurses signed a written consent form before the interviews (Appendix 3) as well as sharing their demographic data (Appendix 4). The interviews lasted between 20 and 66 minutes, the median duration was 31 minutes and the first interview were a pilot-interview. A pilot interview is used to verify the validity and order of the questions (Polit & Beck 2014). The interviews were recorded and then transcribed the same day.
The data collection was done as semi-structured interviews using an interview guide with open ended questions (Appendix 5). By asking open-ended questions and not by using leading questions, in-depth interviews can be obtained (Polit & Beck 2014). To research the
registered nurses’ experiences of counseling young adults about HIV an inductive qualitative approach was chosen. According to Polit and Beck (2014) a qualitative approach is used to gain an in-depth and a context-bond understanding of the purpose.
The interviews were held face-to-face at the hospital with either one or two examiners present at every interview. According to Polit and Beck (2014) the risk of bias reduces if an examiner is monitoring the interview and follows up uncertainties at the end. Therefore, when two examiners were present during any interview one examiner would observe, take notes and asked follow-up questions at the end of the session. Probing questions were used to develop the informant’s answers and they were not included in the question form (Appendix 5). The use of semi-structured interviews allows the researcher to use probing questions and gain broader understanding of the aim (Polit & Beck 2014).
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Table 1. An example of the analyzing process
“ Some they may not ha ve had int erc ourse. They sa y, I ha ve n ev er sl ept w it h some one , w he re did I ge t t he disease ?” “ T he n also the c hall enge of t ak ing t he drugs. T he y tell me they doe sn ’t w ant t o be se
en taking the drugs, so they
sk ip t he m, the drugs eh.” “ Some w ant t he testing, s ome w ant t o k now more a bout i t – is t he re any thi ng done about i t?” “ W e tal k to t he m, we c ou nse l, at least t he y ge t t o k now there is nee d to test and of tal
k about young adults
and the spre
ad of HI V.” “ T he y oung fem ales are more soc ial and they ac ce pt - ac ce ptance some thi ng of t hat so rt.” “ One room wi th t he c hil dre n y ah. Y ou fi nd that w he n the pe r se xs (…) C hil dre n try to adv enture of w hat t he y he ar” “ Am ong thos e prost it utes there are so many y outh. T hose are out of sc hool (…) they e nd up w hat, i n prost it ut ion .” “ Ot he r ti me s there are st igma, st igma to t ell their fri ends” “ T he y are angry . T hat t his t hing, t his HIV w hy of all pe
ople did that
pe
rson get that
HI V?” “ And by the way their w ould, i t can be a famil y of f or e xample four or fi ve c hil dre n and only on e of t he m be co me s HI V -p osit ive , others are ne gati ve . Do y ou thi nk th e li fe is e asy w he n y ou se e y our si sters are free ?” “ T he y fear going t o tell t he ir f ell ow fri end, the wa s, the k now they are posi ti ve , they fear the ir f ell ow fri ends” In te rview t ran sc rip t Young a dult s e ff orts to se lf -c are Young a dult s e ff orts to se lf -c are Young a dult s e ff orts to se lf -c are A c ompl ex e nvironmen t to counse l young adults in A c ompl ex e nvironmen t to counse l young adults in S oc ial Ec onomi ca l cha ll enge s li nke d to HI V S oc ial Ec onom ica l cha ll enge s li nke d to HI V S oc ial Ec onomi ca l cha ll enge s li nke d to HI V Young a dult s’ f ee li ngs associa ted w it h HI V. Young a dult s’ f ee li ngs associa ted w it h HI V. Young a dult s’ f ee li ngs associa ted w it h HI V. T h em e Tr ansmi ssi on ro utes of H IV Young a dult s a dhe re nc e P re ve nti on to l im it the spre ad of HI V Inf orma ti on a bout HI V Young a dult s B eha vior Livi ng in poor ac comm oda ti on Ec onomi c de pe nd enc y S ti gmatiza ti on of HI V F ee li ngs of a nge r A f ee li ng to be a li en ate d Young a dult s fe ar Cat egor y
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Data analysis
The material was analyzed by a qualitative content analysis inspired by Burnard’s (2008) inductive approach to analyze qualitative data through four steps: Firstly, open coding was done by different aspects in the transcribed interviews were summarized into short phrases and written down in the margin. The first step was done simultaneously and separately by both examiners. At this time all drosses were kept through the analysis process as it was not certain what information could be used in the end. According to Burnard (2008), a dross is whenever an informant is clearly going of track throughout the first step of the analyzing process, this part in the transcript will not be coded because it does not answer the intended purpose. Secondly, both examiner’s numbers of short phrases were compared to the other’s list. When a united list had been created, overlapping categories were identified and worked down into 11 categories, to reduce the number of short phrases into a manageable amount of data. Thirdly, the categories were color coded, as well as all drosses that emerged through the analysis were now deleted. All data except for the drosses in the transcriptions was sorted into the coded categories as the data becomes more organized. Further, the list of color-coded data was transferred into 11 different documents to achieve an overview of the result. According to Burnard (2008) themes and categories can be found and verified by repeatedly going through the material, furthermore after reading the data again all categories were sorted into four themes.
Ethical considerations
Before starting to collect data, the project plan with the arrangements on how to address ethical issues was assessed by Malmö University’ Faculty of Health and Society’s Ethical Council with the event number HS2018 64. Furthermore, Lubaga Hospital’s Research Review Committee approved an ethical review with the event number LHREC/2018/41 (Appendix 1). Before every interview the informant obtained written information about the study, how the interview would proceed and the participant’s rights. The participation was completely voluntary and the informant could at any time end their involvement without any explanation. All interviewed registered nurses followed up the entire interviews. Their decision to
participate or to decline did not lead to any consequences for the registered nurses. According to World Medical Associations (2013) definition of the Information, informants have the right to get adequate information about the purpose and method, any risks by participating and their participation. To ensure that informed consent was obtained the informant had the opportunity to ask question before signing the document consent form (Appendix 3). All interviews took place at the hospital whenever the nurses had time. Demographic data (appendix 4) was analyzed and reported at a group level to ensure what World Medical Association (2013) calls
Confidential, to protect the secrecy of the individual and their answers. Further, the
Confidential principal put pressure that the management and storage of data to prevent data leakage (ibid.).
Immediately after the interviews had ended, the recordings were transcribed and coded into anonymous identification codes. Two lists were created of the codes and the informant’s names, they were stored separately. The recorded material was stored at a recorder and the transcribed interviews were saved on two different flash drives. Neither were shared online, except for the first transcription which was send to the supervisor for guidance. The analyzed results were saved in the cloud for backup if the flash drives would have crashed. The results are presented on group level with a few quotes with no identifying data linked to them. The Declaration of Helsinki declares how Publication and Dissemination of Results should be managed (World Medical Association 2013). To live up to the Declaration of Helsinki the
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informants obtained the study results by request as well as receiving information about any publication forums.
RESULTS
The registered nurses working at Lubaga Hospital counseled young adults in a few different settings, one-on-one and face-to-face, in groups at the hospital or in the communities. The median age of the informants were 31 years old (26-58 years old). It was ten women, two men and the median working experience as a registered nurse was nine years (3-37 years)
Furthermore, the median for working with HIV was five years (2-22 years). By analyzing the transcribed interviews various short phrases were extracted. Later they were divided into 11 categories. Lastly all categories were sorted into four themes: young adult’s feelings
associated with HIV, socio-economic challenges linked to HIV, a complex environment to counsel young adults in and young adult’s efforts to self-care.
Table 2. The themes and categories
Theme Category
Young adult’s feelings associated with HIV Young adult’s fear A feeling to be alienated Feelings of anger
Socio-economic challenges HIV-related Stigmatization Economic dependency
Living in poor accommodation A complex environment to counsel young
adults in
Young adult’s Behavior Information about HIV
Young adult’s efforts to self-care Prevention to limit the spread of HIV Young adult’s adherence
Transmission routes of HIV
Young adults’ feelings associated with HIV
The first theme contain the following three categories: young adult’s fear, a feeling to be alienated and feeling of anger. In summary, the categories include information about young adult’s feelings towards HIV-related stigma and vulnerability because of them being financially dependent to others.
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Young adult’s fear
The informants described the category fear is a complex area as young adults dreads several things related to HIV. For instance, to tell their parents and their partner, the health-care system and of their future. Additionally, the informants think that young adults also fear to be chased away from their communities, to be physically violated and to be cursed in case their HIV-status are revealed. Furthermore, the registered nurses said that young adults are scared they soon will die and as a result they believe that they will not get a partner and not have a family of their own. Moreover, HIV-related stigma may cause fear, which they think will make it harder for them to get a job. Although HIV is stigmatized, young women would rather get HIV than become pregnant as a pregnancy would show and HIV would not. According to the informants the fear to be caught to have had sex before marriage would prevail compared to be found to be HIV-positive.
“They fear getting pregnant. Before eh instead of fearing getting the HIV. They get that, what, they fear getting pregnant, instead of fearing getting HIV. Because for them they fear their parents to know that they have boyfriends.”
(Informant 1).
On the other hand, if young adults are HIV-positive due to being raped, they fear telling people and seek help because of the shame linked to HIV. According to the informants are young adults afraid to take ART-medication in public, especially in exposed areas such as in student accommodations or at school. At hospital and healthcare facilities young adults may feel misunderstood due to the registered nurses being of another generation. As a result, they dread going, which affects their adherence and how regularly they are being tested for
HIV. Besides, the anxiety of them being caught by an acquainted when going to test for HIV or pick up medication at a healthcare facility prevail good adherence and testing. However, the informants think counseling may help young adults to overcome their fear, but it takes time and acquires the registered nurses to be accessible and to reach out to their patients.
A feeling to be alienated
The study participants brought up that young HIV-positive adults may feel alienated, especially if they do not know anyone else with the same status. Moreover, young adults living with HIV wish to have a family and a partner. On the other hand, they do not want to spread HIV, hence they are searching for a person with the same status as themselves. At Lubaga hospital, they got groups with HIV infected people. In those groups the group
members get to know each other and uses those relations to feel less alienated and maybe find a partner.
Feelings of anger
According to the informants, if young adult have been infected with HIV at birth this may cause them to feel anger at their parent and/or God. They are questioning why their parents were not more careful and why they acted irresponsible, thus the young adults are the ones to be affected in the end. They have been forced to take ART-medication since birth and never got an explanation to why while growing up. Their anger causes them to have poor adherence, them to silence and fail to open up. Moreover, the registered nurses think that young adults are also angry at God and may wonder why they got infected as they did not do anything wrong.
“Telling that youth who was not even engaged in love affairs sexual what and
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father. They are really angry. If the parents are still alive they are really angry with them.” (Informant 2)
Socio-economic challenges linked to HIV
The three following categories in the second theme is: HIV-related stigmatization, economic dependency and living in poor accommodation. The covers patriarchal oppression, economic vulnerability and stigma in the society related to HIV, which may cause young adults to get infected with HIV or lead to a poor adherence.
HIV-related stigmatization
The informants raised the issue of young adults facing HIV-related stigmatization, sometimes resulting in discrimination: Which cause them to struggle to fit in, tell others and to have poor adherence. There is a possible risk to face discrimination by either students or the teachers.
“They came some, they came, with rashes, and they disappeared from those
cause. They say when I go there they laugh for me. I don’t want to go to school, some they don’t want to go from out the house. Then if we knows. If we have, if we the parents are from here, we talk with them, we go at home, even at school, we go there, to talk with the teachers. You know even some teachers were not good. They wanted to talk, even to tell the others, this nanny, the other children, they see them, laugh and say: Eh This one has AIDS. So, some they don’t want to go to school, but when we go there we talk with the whole, the entire school, the members even the students.” (Informant 3)
According to the informants some young adults are still under parental supervision, even past the age of 18. Some of them still live at home or are economically dependent on their parents due to school fees or student housing. The registered nurses claimed that this combined with a cultural expectancy to not to engage in sexual activities before graduating and marriage could result in several consequences. If young adults were found to have had sex before marriage it could culminate in them being discarded from their home environment, stigmatization and punishment.
Economic dependency
Mainly young women but also young men have sexual relationships because of financial reasons and as a result the risk to become infected with HIV increase. The registered nurses had experiences of young female adults going into prostitution and meeting older men to be able to get a higher standard of living.
Living in poor accommodation
The informant mentioned young adults that have been living in poor accommodations when they grew up. Due to small living space the young adults witnessed their parents having sex which resulted in them engaging in risk full behaviors, early sex debut and hang around with people with bad influence.
“There is not good parents to sleep in one room with the children. One room
with the children You find that when when the per sexs. The children hears what is going on, wrong things. Children try to adventure of what they hear.”
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(Informant 4)
A complex environment to counsel young adults in
Two categories were identified in the third theme: young adult’s behavior and information about HIV. Both categories are describing benefits and obstacles to counseling young adults and how the environment can be a challenge for the registered nurses.
Young adult’s behavior
The interviewed registered nurses said that there is a gender difference when counseling young adults. Young women are easier to talk to, they accept the treatment and information, understand fast and interact well. They also have been bigger social capacity and are better at associating compared to young men. On contrast, they can also be stubborn, rude towards healthcare professionals and their parents, they tend to be quiet and shy in group counseling. However, after the group counseling session is over, they come up to the nurse and ask questions and start to open up.
The registered nurses brought up young men’s behaviors as well: they can be difficult to talk to, hard to interact with, they do not associate well and tend to have many women at the same time. Moreover, they can break up with a partner quite easily if they do not satisfy him. In group counseling settings young men tend to take over, they are loud and more outspoken than young women. Contrary, young men may be open and honest about their sexual behaviors, which makes it easy to work with them. They are curious, are asking questions because for the purpose of disease eradication.
The informants raised the topic group counseling independent of what gender the group had. Overall, they find it difficult to give information and counsel young adults in a group. They are not focused and do not take in the information.
“Whenever you tell them something those teenagers 18- 24 they are too difficult. They
looked to someone to telling them, eh the just laugh, in group, I think it is a group. It is a peer group maybe you seen them to do like that. Yeah. They don’t take it as good as how would I say. They don’t take it as good as it is.” (Informant 3)
When the registered nurses talked to the young adults individually, they interact better. They were more interested to be tested, to ask questions and they are more serious.
Information about HIV
The results show that registered nurse’s information and education took place in a few different settings. On the first hand, individual counseling is common. On the other hand, so is counseling in groups. The informants brought up that they are going to places where it is like that young adults are, such as schools. They find that they are able to reach out to more people this way and are able to educate them about HIV, ART-treatment, prophylaxis for instance the ABC-method and PrEP and at the same time able to test young adults for HIV. The informants find that young adults do not want to receive their test-results, because of them not getting the information they risk spreading HIV to others.
In case of rape the informants explained that they had to take certain precautions when they are informing the victims. They educate them about the importance to come and see someone
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at the hospital, about PrEP and HIV-testing. If it is not known who the offender is, they try find who it is and test them for HIV as well.
The informants identified an individual need of education within young adults because the level of knowledge varies. However, the registered nurses explained that they usually counseled young men and women about disease transmission-routes, prevention and how their patient’s experiences, before they test for HIV. Moreover, to be able to burst rumors disseminated among young adults it is important to counsel young adults.
“They normally for them they think, that if you go for HIV-testing and you take
an aspirin tablet it will always be negative. If you come for HIV-testing and you take a Coca Cola, the soda, that soft drink the virus will be suppressed and you will test negative. And they even tell you what if I got to test for HIV as a couple and then my partner takes a Coca Cola and it shows negative. Is it possible for him to infect me? After him testing negative just because of the Coca Cola. Some think it is true. But we continue to educate them.” (Informant 5)
Young adult’s efforts to self-care
In the fourth and last theme three categories emerged: prevention to limit the spread of HIV, young adult’s adherence and transmission routes of HIV. The categories cover young adult’s ability to adhere to advice after being counseled by registered nurses and some explanations to why some young adults have been infected with HIV according to the informants.
Prevention to limit the spread of HIV
During the interviews the informants raised the topic of prevention: The ABC-method, PrEP, the importance to test for HIV and counseling to educate patients about what to do if they are found to have HIV. Young adults are encouraged to go and find out their status every third month and before they have sex with a new partner. However, it is more young women are more likely to come for HIV-testing even when they are in a relationship with a man. Both of them are not coming to test. According to the informants, if a young man that is in a
relationship and he is asked by their partner about his HIV-status, they could lie and therefore expose themselves and the other person for a greater risk to become HIV-positive.
“We try to tell them to have one partner. They should learn their, the girl for friendship teach them together and they have to use condom, condom use, consistently and wisely. Or never, or to abstain completely. If they are in, not, education they have to finish their education first. Wait for the right time and when they got a partner they have to come together with the partner for test before they indulge in sex.” (Informant 6)
Moreover, according to the informants it varies in how their patients are trying to protect themselves from become infected with HIV. Some wait to have sex until after marriage or until they have finished university and are economically independent. Others finds out their HIV-status before they have intercourse and use condoms. If they have had unprotected sex young adults are, according to the informants either keen to get PrEP or to start with ART-therapy. Some want to learn more about how to protect themselves and as a result they either ask healthcare providers or research on their own.
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Young adult’s adherence
A few different reasons why young adults may have a poor adherence were discovered: A reason is lack of time because of schoolwork or because they did not want anyone to know that they are taking ART-medication. The registered nurses pointed out that the HIV-positive young adults could be fed up by have had to take medication for a long time. Lastly, some young men and women may feel ashamed of being HIV-positive hence they ignore or do not take in that they have a chronic disease which need life-long treatment.
Overall, they think that young women have a better adherence, which they explained occurred due to them having the responsibility to take care of the children and had to have better
adherence for another person's sake. Also, the study participants believe that young adults may overcome feeling that are preventing them to have a good adherence and start to open up by repeated counseling sessions.
“When a woman has a kid, it is because for her. They tell her that you are the
one in immediately care of your child (...) Only that one because the love she has for her kid, she be first that.” (Informant 7)
Transmission routes of HIV
The informants explained the high prevalence of HIV in the ages 18 to 24 years old is partly understood by the mother to child prevention program not being implemented at the time, when they were born. Others they have had unprotected consensual sexual contacts. Furthermore, the study participants believed that young women sometimes became HIV-positive by being raped or by going into prostitution. They talked about how patriarchal oppression is an explanation to why young women are infected. According to the registered nurses, it could be dangerous to be out along during night for women and thus be at risk of being raped. Furthermore, relatives or partner may be guilty of taking advantage of them while growing up. Moreover, the informants explained that if a prostitute agrees to have sex with a client without a condom, they get paid more compared to have safe sex. This increases the danger of the woman to have unsafe-sex and thereby the risk to get HIV.
DISCUSSION
The discussion contains three parts: discussion of method, ethical discussion and result discussion. The first part is analyzing strengths and weaknesses of the method. Secondly, ethical dilemmas are brought up and debated. Finally, three results are discussed in relation to Bandura’s Self-efficacy theory and previous research.
Discussion of method
According to Graneheim and Lundman (2004) trustworthiness is a combined measure of every procedure in a study and an evaluation of all choices that are made. The level of trustworthiness in research can be measured through three variables: Credibility,
dependability and transferability (ibid.).
The level of credibility is determined by data accuracy and method of analysis addresses the purpose (Graneheim & Lundman 2004). The first four informants were chosen by a
representative from the research department at Lubaga Hospital, it may have had an impact on which nurses that were picked and thereby the final result. Later, the recruitment occurred without any person from Lubaga Hospitals’ involvement, then a few nurses denied
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participating. A patriarchal difference in the recruitment process was detected. The distinction showed as the male examiner got informants rather easily when the research department worker did not accompany and the female examiner did not. It is possible that the registered nurses felt pressured to participate whenever the male examiner asked them, this could have affected who participated and eventually the final result. In the end convenience sampling was used to recruit informants. A risk by using convenience sampling is that all aspects of the purpose might not get explored, as the representation of participants is not representative for the majority of possible informants (Polit & Beck 2014).
A way to enhance the credibility is to seek agreement with one person or more, who are carrying out the data collection, coding and the analyzing of data independently (Polit & Beck 2014; Graneheim & Lundman 2004). This reduces the risk of an examiner to be biased (ibid.). To minimize the risk systematic overlook of certain data in the analyzing process, the first step of the qualitative content analysis was done separately by both examiners. No big differences were found when the lists of short phrases were compared.
During the data analysis it was found that the question: From your perspective as a nurse,
why is it important to counsel young adults about HIV? (Appendix 5) did not consistently
capture data addressed to the intended purpose. The nurses answered the question out of their own perspective as registered nurses and not in a way which indicated that they had come to the conclusion through counseling young adults about HIV. The question: Where else have
you been working as a nurse? from the demographic data collection, (Appendix 4) did not
result in a result, as the registered nurse’s answers could not be analyzed because it was not certain in what field they had worked in or in a few cases where they had been working. Ineffective questions lower the credibility of the final result as the data will not answer the purpose (Graneheim & Lundman 2004).
Dependability is how much the data changes over time due to changes in the examiners way of collecting and analyzing data (Graneheim & Lundman 2004). A short time frame makes the results more dependable as few alterations would have occurred (ibid.). All data was collected over a period of two weeks and the analysis took five days to complete with
exception for the last read through, three months later. The same questions were asked during every interview but one, as the question: Does anything differs when it comes to counseling
young male adults compared to young female adults? was forgotten. The informant did
discuss gender differences anyway, but they did not answer the question itself. Because all questions were not asked consistently the same areas were not researched. Inconsistency of how data is collected decreases the dependability (Graneheim & Lundman 2004). After one of the interviews it was discovered that the recorder did not function. The following week, the same registered nurse was interviewed and did not add anything compared to the first session. However, it was clear that the informant remembered the interview guide because informant answered several questions right from the start.
The level of transferability is decided by the reader and depends on the method, how well all steps throughout the study is and the context is described (Graneheim & Lundman 2004). If context bound factors that are affecting young adults in relation to HIV are similar to the environment which this study took place in, the level of transferability increase. Such factors may be socioeconomics, patriarchal structures and the overall view of HIV in a society. However, thus a qualitative approach was chosen and 12 registered nurses have been interviewed, the level of transferability decreases. According to Polit and Beck (2014), the intention of a qualitative study design is not to compare large populations or to generalize.
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Furthermore, vivid and representative study population increases transferability (ibid.) thus, 12 informants is not a sufficient to be able to generalize the findings.
Ethical discussion
Two ethical dilemmas were found in the recruitment process. Firstly, a representative from the research department at Lubaga Hospital picked the first four participants. The registered nurses did not get information before and the person stayed until they gave an answer, hence the nurses could have felt pressured to be interviewed. Secondly, the male examiner recruited informants easier than the female examiner. The registered nurses might have felt pressured to participate when the male examiner asked them to partake. Before every interview it was communicated to all informants that their participation is based on free will and that they could cancel their participation at any point without any consequences, as the research department of Lubaga Hospital would not be informed. Two nurses did decline to participate after receiving the information (Appendix 2). Informants have the right to be informed about the study and their involvement, they can also deny participating or quit at any time, without any risks (World Medical Association 2013).
Result discussion
The purpose of this minor field study was to describe nurses’ experience of counseling young adults about HIV, in relation to increasing numbers of newly infected people in the ages 15 to 24 years old. Moreover, counseling is a common task for registered nurses and is used to reduce high-risk behaviors. Our results showed that the informants believe that counseling has a positive effect to reduce young adults fear and bad behaviors but also to limit the spread of HIV.
Discussion about fear of the healthcare system
According to the informants, young adults fear the healthcare system thus they hesitate to visit healthcare facilities, do not want to be counseled, pick up medication or undergo free HIV-testing. Bandura’s (1997) self-efficacy theory with its’ four modes: enactive mastery
experience, vicarious experiences, verbal persuasion and physiological and affective states,
could be used in educational purposes. The theory is used by the informants to earn trust from the young adults. By using verbal persuasion and continuously trying to eliminate any
insecurities and the discomforts young adults may feel when going to the wards. They empower their patients and points out the discrepancy between the positive effect and negative effects by going or not. Furthermore, by incorporate the mode physiological and affective states, registered nurses may assess their patients with for instance verbal persuasion through counseling. However, firstly they need to determine how the young adult’s general health is and how they cope with stressors.
As stated by the informants, young adults being afraid of being open about their HIV-status, they try to hide that part of themselves. Self-disclosure is according to Gabbidon (2019) a person’s free choice to share their HIV-status with someone else. According to Candace (2014), by opening up about their status, young adults could improve their feeling of
wellbeing, be less isolated and get a better social support from their families which may lead to better adherence and prevent the spread of HIV. However, factors such as gender, sexual orientation, age stigma and a lack of social support prohibits the level of openness of their HIV-status (ibid.). Gabbidon (2019) argues in their systematic review, that the most common
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person young adults were discussing their status with were firstly any romantic partner and secondly their friends. Our results showed that registered nurses think young adults fear to be stigmatized, of their parents and their partner as they fear to be rejected, physically abused, cursed or to have an unwanted pregnancy thus it would have shown that they have had sex. Without social support many young adults may face isolation and financial struggles hence young adults may fear rejection because of their HIV-status.
Discussion about stigmatization in the society
The informants brought up different kinds of stigmatization and according to the informants the young adults fear the stigma because they do not want to be alone, left out of the society. Moreover, they claimed that young adults are afraid of being bullied because they have HIV hence, they are afraid to take ART-medication. Bandura’s (1997) mode vicarious experiences in the self-efficacy theory about observational learning can make it difficult for the young adults to overcome the fear of stigmatization. In this mode the people learn to believe in their own abilities by observing others, in this case their surroundings and the society which they live in. A person is influenced and taught by watching how PLWH are treated. Because of what they observe, they think less of their own abilities and their self-efficacy diminish. They think that if they tell people that they have HIV they will get the same treatment. Because of HIV-related stigma it is harder to prevent the spread of HIV, treat and nurse people with HIV (Tam 2011). Feyissa (2018) argues that there have been several global and national
interventions to reduce HIV-related stigma. Firstly, to empower PLWH to be able to cope with stigma. Secondly, information and counseling about HIV. Thirdly, structural changes such as external stigma. Fourthly, biomedical intervention like universal access to care. Lastly, to increase PLWH’s sense of coherence and contact-based approaches (ibid.). The registered nurses use the verbal persuasion mode when they meet the young adults. They inform about HIV and are trying to help to change the view of HIV in the society (Bandura 1997).
Discussion about the young adult’s behavior and information about HIV
The registered nurses did counsel in both groups and individual. They thought it was easier to counsel them individually rather than in groups because big groups tend to be unfocused. Individual counseling with a counseling protocol to educate PLWH about HIV, is according to Musayón-Oblitas (2017) effective to enhance adherence. However, how long every session should be, how many meetings is required or details of how counseling is performed uncertain (ibid.). According to Ridgeway (2018) there is no evidence to support the effectiveness of group counseling, neither effective interventions to improve adherence within young adults. The registered nurses use the verbal persuasion when they meet the young adults in both group and individual counseling. They always try to convince them the importance of HIV-testing and taking the medication through positive-motivation for completing the task. (Bandura 1997) There is a lack of knowledge about effective interventions of how to care for young adults with HIV in Sub-Sahara (Mavegam 2017). Our results show that the registered nurses actively went out to places where young adults might be to educate them and to test for HIV. The registered nurses tried to convince young adults to come to health facilities and test for HIV. This could be interpreted as that the informants used Bandura’s (1997) mode verbal persuasion to get the young adults to the clinics for testing. The registered nurses could convince the young adults about the benefits of testing and in the same time give them information about HIV. When the young adults get this positive encouragement, it is more
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likely that they will come to the clinics (ibid.).
Discussion about prevention to limit the spread of HIV
According to the informants, some young adults are using different preventive methods to protect themselves from getting HIV. Some uses condoms, a few tests and finds out their own status before they have sex and others are abstaining until after marriage or until they are finically independent. It is likely to assume that he young adult who are taking measures to protect themselves from HIV have a rather good self-efficacy. According to Bandura (1997), self-efficacy is a person’s believe in their own capacity to succeed at a task. Because the task is to not get infected with HIV and in addition to potentially suffer by HIV-related
consequences. Those young adults who protect themselves may have observed the registered nurses they have been in contact with, when being tested for HIV or during counseling. Hence, their self-efficacy may have increased due to enactive master experiences or verbal persuasion. Enactive mastery experience is when successful experience confirms and empowers a person that they can succeed (Bandura 1997).
According Bandura (1997) is low self-efficacy correlated to low levels of the four modes. To be able to reach the 90-90-90 target and to end the AIDS-epidemic until 2030 the Uganda AIDS Commission (2015) argues that they must strengthen interventions in three areas: prevention, care and treatment and social support and protection. According to Faust and Yaya (2018) education interventions, such as peer learning and counseling increase awareness and knowledge about condom use and the effect. Hence, learning interventions also limit the spread of HIV. It is important to work against gender-based violence prevention and
socioeconomic challenges to make prevention programs more accessible to vulnerable groups for instance young adults and women (Uganda AIDS Commission 2015). If preventive programs are more available, maybe their physiological and affective states will improve and more people will be able to attend to self-care. According to Bandura (1997) if the
physiological and affective states of a person is increased, the chance of them succeeding a task will improve.
CONCLUSION
In conclusion high-risk behaviors such as an early sex debut, several sexual partners and unprotected sex are believed to be the reason of the high prevalence of newly infected young adults. Since registered nurses counseling is effective to limit the spread of HIV among adults it is possible it could have positive impact on young adults as well. According to the results, registered nurses are experiencing various factors that burdens but also facilitate counseling. A few of which have to do with young adult’s behavior in counseling situations, others with internal and external stigmatization and economic vulnerability. However, some young adults have an ability to focus, interact with the registered nurses and associate well. Qualities which make it easier for them to peruse self-disclosure and potentially have a better mental health, greater social support system and make them feel less alienated. Furthermore, self-disclosure could help to limit the spread of HIV and to improve adherence. The findings of this study are limited by a small number of informants, not reaching data saturation but also the fact that some nurse might have felt pressured to participate in the study. Moreover, a limitation is due
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to an ineffective question and non-continuity of which questions that where asked during an interview. However, it is clear that young adults fear of HIV, HIV-related stigma and socioeconomic factors pose an obstacle when counseling young adults about HIV.
SUGGESTIONS FOR DEVELOPMENT AND QUALITY
IMPROVEMENT
The purpose of this study is to describe registered nurses’ experiences of counseling young adults about HIV. Hopefully, all study participants, the staff at the three wards and the
research department at Lubaga hospital will find the results helpful in their daily activities and will be able to implement the findings into their place of work. The result was not
comprehensive and it stood clear throughout the discussion that in some areas there is little research done.
We recommend that future studies should research how to care for young adults with HIV, in Uganda or how to increase young adult’s adherence, linked to HIV in Uganda. Thus, little research have been carried out focusing on nursing and caring for young adults linked to HIV When we stared out, we had a wish to do a Minor Field Study. Although we did not have any specific idea of what the topic should be, in the end we are more than happy about our choice. We have learned a lot about the research-process and HIV-care, both how to prevent the spread of HIV and nursing for HIV-positive people. Throughout the study we have come to understand the complexity of nursing in HIV and we are intrigued to learn more about Uganda, internationalization and nursing people living with HIV.
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