Much of the literature suggests that health workers in sub-Saharan Africa, especially nurses, rarely show positive attitudes and behaviours towards clients who access HIV counselling, testing and treatment services. In the few studies where health workers were reported to have shown positive attitudes towards clients, no mention was made of the specific type of attitudes or behaviours. Adebajo et al. (2003), for
instance, reported in their study that 90 per cent of care providers in Nigeria agreed to treat persons with HIV/AIDS. Fusilier et al. (1998) also indicated that 81 per cent
of health care workers they interviewed were willing to provide AIDS care. Quach
et al. (2005) observed in their study that a third of physicians they interviewed had
positive attitudes about providing care to HIV/AIDS patients. In essence, the good attitude these studies found was the willingness of care providers to treat positive persons. The present study also found that most health workers had good perception of clients and showed positive attitudes and behaviours towards them during interactions.
Warm reception
It was observed at the centres and clinics that health workers often gave clients a warm reception. Nurses embraced or hugged clients who have not visited the clinics for a long time.2 Medical doctors and counsellors in the clinics and centres also welcomed clients with a smile and readily offered them a seat. They asked clients about their health and sometimes that of their families, before they were treated or counselling started. A client, Owusua, who had just gone through counselling and testing, gave me her impressions of the way the counsellor received her:
2 I refer to clients who have adhered to ART treatment for at least one year. Health workers describe them
as ‘trusted clients’ and most of them have good relationships with health workers. As a result, their visits to the clinics for a review of their CD4 count and other tests are often scheduled between three to six months. Also, unlike new clients, they are allowed to buy ARV drugs for three to six months in advance.
Oh… The counsellor received me very well… by first asking about my health and that of my husband and children. He even offered me some water to drink when I tried to clear my throat in order to speak out clearly. Though the test showed that I do not have the disease, the way the counsellor nicely talked to me has encouraged me to come back in three months time for another test as he has requested.
Health workers for their part explained that they gave clients a warm reception to motivate them to continue accessing care and treatment. According to them, some clients have strictly adhered to the treatment and survived HIV/AIDS. Such clients have become role models for other clients who have persistently defaulted in their treatment regimen. They hugged or embraced these clients to motivate defaulters to adhere to treatment and feel appreciated by health workers. The health workers pointed out that experience in the facilities has shown that warm reception towards clients has encouraged many of them to continue accessing treatment.
Clients also explained that they were motivated to continue doing the right things about their treatment whenever care providers gave them positive compliments like a hug in the presence of their peers. For instance, a client who received a warm reception from nurses a couple of times in the clinic said the following in a conversation:
I always feel happy whenever I come to the clinic and hear one health worker after another saying that I am looking good. Anytime they embrace me, it makes me feel that after all somebody loves and appreciates me. I have even been used as an example [role model] to counsel some clients who had lost hope that they would not survive the disease. The good reception I always receive from this doctor [she mentions his name] and the nurses here has encouraged me to regularly take my medicines and visit the clinic on appointed dates. (Asam- pana, a client)
From the views of health workers and clients, it can be said that the warm reception health workers give to clients has led to some kind of bond and affection between them and this has subsequently encouraged some clients to adhere to treatment.
Courtesy
Another way health workers behaved favourably towards clients was how they addressed them during consultations or conversations. I closely followed the way that care providers addressed clients to find out whether the perceived stigma associated with HIV/AIDS had negatively influenced the respect and patience they have for them. Observations in the facilities showed that most of the health workers addressed clients politely. For instance, I heard doctors, nurses, counsellors and other staff addressing clients with traditionally accepted phrases and honorific titles such as ‘please’ (mepa wo kyɛw), ‘elder’ (cpanyin), ‘madam’ (maame), ‘my friend’
(m’adamfo), ‘lady’ (awuraa) and ‘young man’ (abranteɛ) before they talked to
them. The titles showed that these health workers respected clients irrespective of their status.
Two particular health workers, one in a clinic and the other in a centre, were noted for addressing almost every client they came into contact with in one of the traditionally accepted ways as described above. One of these two health care providers was Martinson and I observed that many clients always wanted him to attend to them on clinic days. Addae, an elderly client in a conversation, confirmed this assertion and added that unlike some of his colleagues, Martinson addressed clients with courtesy. According to him, the health worker always addressed him as ‘father’ (agya) before he talked to him. Addae pointed out that this was a sign of
respect Martinson had for him as someone who could be his biological father, and not as an irresponsible old man who presumably got the infection through immoral sex [the client laughed].
Another client mentioned a nurse called Benedicta as a health worker who also addressed both old and young clients politely in one of the clinics. The client pointed out that she usually addressed male clients as brother (me nuabarima), and
female clients assister or (me nuabaa). Besides, she always prefixed her communi-
cation with clients in clinical encounters with “please”.
Financial support
A study of records in the centres and clinics with regard to the socio-demographic characteristics of clients showed that over 85 percent of them were relatively poor. Most of these clients faced financial difficulties in making out-of-pocket payment for certain health care services not covered by the National Health Insurance Scheme (NHIS).3 The majority of them were unemployed and they attributed this to different social and economic factors. Some of the clients explained that they became unemployed after they got the infection. Others said that before they were diagnosed positive, they had taken their prolonged health problems to many places including hospitals, prayer camps, traditional healers, herbalists and fetish priests for solution or cure. At each of these places, they spent large sums of money to get treatment, although they never succeeded. A few of them pointed out that they lost their jobs because their employers thought they were spending too many working hours in hospitals accessing treatment. It was obvious that it was difficult for most of them to make a living. The following comment made by Benewa, a client, captures the poor financial situation of most of the clients.
3 The Government of Ghana introduced the NHIS in 2003 to replace the Cash and Carry system. Under the
old system, citizens made out-of-pocket payment for all health care services. But with the NHIS, Ghanaians are supposed to pay a yearly premium which entitles them to access most health care services free of charge. However, the scheme does not cover certain health care expenses including the cost of ARVmedicines for treating HIV/AIDS. As a result, PLWHA are supposed to make out-of-pocket payment for the supply of ARV medicines every month. During this study the cost of these heavily subsidized medicines by the Ghana government was five Ghana cedis (almost five US Dollars). However, over 85% of PLWHA who are on these medicines are not able to buy them because they are either poor or unemployed. In order to enable every PLWHA to have access to these medicines, the ART clinics have a policy which allows clients to buy the medicines on credit.
As I am speaking with you now, I do not know how I am going back home after treatment let alone think of the food I must provide for my two children this evening. Take a look inside my purse – she opened her purse for me to see but I refused to look inside – there is not even one Ghana cedi – almost one US Dollar – for me to take transport back home. At least for the medicines, I know I can buy on credit but then, after taking the drugs, I have to eat; my children too have to eat before I can think of other things I need money to take care of. In fact, it is financially hard for some of us (throwing her hands in despair)
It was such dire financial difficulties among clients that led some nurses in the clinics to give financial support. The support from health workers to clients helped them to take transport back home after accessing treatment, as seen in the case of Serwaa in Chapter One, or buy food. For instance, Marie, a health assistant, used her own money on many occasions to buy food for clients who reported to the clinic in a weak condition and almost out of breath because they did not have money to buy food. Clients were always grateful to health workers for supporting them financially.
Counsellors in the centres sometimes paid the cost of counselling and testing for some clients who could not afford the service. The cost of counselling used to be one Ghana cedi (almost one US Dollar) in government health facilities, but the service was made free from March 2009 (NACP/GHS 2009) to encourage more people to undergo counselling and testing. The financial support health workers gave to clients not only helped them buy food or pay their transportation cost, but also to pay for the cost of care and treatment.
Advice
The favourable attitudes of health workers went beyond their official roles as counsellors and providers of health care. Some clients had taken health workers as their personal advisors on a wide range of issues beyond care and treatment, as is made clear in the comments by Abrefi at the beginning of this chapter. Health workers willingly accepted this role and acted it with enthusiasm. Clients were seen in the centres and clinics discussing their health, marital and family problems with health workers.
On one occasion, Naa, a client, approached a senior nurse, Suzane, for advice on a marital problem. According to the client, she lost interest in sex when she started taking the ARV drugs but her HIV-negative husband was not happy with her reluctance to have sex with him. Naa said her husband started coming home late after close of work and this gave her cause to suspect that he was in love with another woman. So, she asked nurse Suzane to advise her on what she should do to solve the problem with her husband because the man’s change of attitude towards her was giving her sleepless nights. Suzane, who the client had adopted as an elder sister, invited the couple to the clinic for a discussion on this issue.
Two months later, I met Naa in the clinic full of smiles and asked her whether she was able to come with her husband to see the nurse. She answered in the affirmative and explained how the nurse’s advice helped to save her marriage. According to her,
the nurse explained that loss of interest in sex was not one of the known side effects of the drugs. She should therefore do away with the idea that the drugs had made her to lose interest in sex. The nurse told her to psychologically tune her mind onto sex whenever she was going to bed, which could help her to regain interest in sex. Naa admitted that Suzane’s advice helped to bring her marriage back on track and she was grateful to Suzane for her intervention.
A male client called Bempa also recounted how he followed the advice of a nurse and went for a bank loan to start a small business on his own. According to Bempa, he mentioned to the nurse in a conversation that he had been unemployed for more than one year after he tested positive. His health had improved considerably following treatment and he felt that he could engage in some meaningful business to make a living. The nurse advised him to go for a bank loan and start selling used clothing in the market, which he did. The client explained that he never regretted taking the nurse’s advice because his business was going well. Bempa stated that “because of the motherly advice the nurse gave me to start the business, I would never forget her in my life.” It is important to mention that through their advisory role, clients have adopted some health workers as their parents or relatives. They consult them when taking decisions such as those about their treatment and finances. The use of health workers as advisors enables clients to exclude their actual family members from taking decisions in relation to their status and helped clients to hide their status from relatives as a coping strategy against stigmatisation associated with the infection.
Working overtime
It was also observed that health workers in the centres and clinics sometimes worked beyond official working hours of 8 a.m. to 5 p.m. to attend to every client who reported for care and treatment. On clinic days, care providers worked throughout the day without a lunch break. In a conversation with a medical doctor, I asked why they hardly take their lunch break whenever they worked in the clinic. He responded as follows:
Whether I go for lunch break or not, I am the very person who would attend to the clients. Assuming I leave the clients for break of one hour, I would come back and meet them waiting for me. So, I prefer to sacrifice the lunch break time and finish treating them. In that case, if I leave the clinic here for lunch I would not come back again till the following morning. The problem is… only a few of us medical doctors in this hospital here have shown the willingness to work with this type of clients. That is why when some of us come to the clinic here we spend all our time to attend to clients although we are not given any incentives…
Rebecca, a nurse, also explained that although officially they have times that they start work, take lunch break and finish, sometimes health workers in the clinics do not work according to those times. She said that in view of the poor health of some of the clients, they thought it would be inhumane on their part to leave them waiting
while they go for lunch. They usually sacrificed their lunch break time to attend to all the clients as early as possible so that those who came from far away places could return home early enough. Rebecca also explained that if they do not sacrifice a little to help the clients, most of them would spend long hours of waiting in the clinic which means that they would also not close early. She pointed out that it was rather unfortunate that the hospital authorities have refused to give them incentives for working work overtime, yet they were not discouraged. According to nurse Rebecca, they had taken the clients as their brothers and sisters, or even their children who needed their help to live positively with HIV/AIDS. “This is the reason why we have decided to work overtime on clinic days to attend to all clients,” she added.
Similarly, counsellors in the centres attended to clients before 8 a.m. and after 5 p.m. These are the normal working hours for most Ghanaian workers. A counsellor, Prince, said in a conversation that there were occasions he was called to the hospital on weekends to provide counselling and testing to clients. Prince was of the view that as a counsellor, one must always be ready to provide the services at anytime so that clients would not use the absence of the counsellor as an excuse not to access counselling and testing.
What is even more, clients could call health workers on their cell phones at any time of the day to talk about their health problems. These health workers willingly gave their mobile phone numbers to clients to call them whenever they needed counselling or advice on their health and other problems. Martinson pointed out in a conversation that it was common for clients to call them in the middle of the night to talk about their health problems. Martinson gave an instance in which a client called him around 2 a.m. and complained about headache. The health worker said that after he advised the client on what he should do to stop the headache, he asked himself “Oh! Is it because of common headache this client woke me up around this time of the night?” This shows that health workers do not only work overtime in the clinic but also outside the clinic and at odd hours.
Interacting comfortably
On the whole health workers openly interacted with clients without hesitation. In the clinics for instance, they were found holding the hands of positive persons or touching them with ease during conversations. Furthermore, health workers often engaged in private conversations with clients and their relatives who accompanied them to the access treatment outside the clinic premises. I eavesdropped in the conversation of two clients and one of them, Fosua, described the way nurses in a clinic easily interacted with clients as follows:
I feel encouraged by the behaviour of the doctors and nurses in this clinic because they freely interact with clients. Unlike the other hospital where I first went on admission … before I was