CHAPTER THREE

3:1 INTRODUCTION
This chapter provides a detailed section of how the practicum was achieved

3:2 PERMISSION SEEKING AND AUTHORIZATION

The researcher made the intention to carry out the practicum known to the hospital authorities. This was achieved through an application to the medical superintendent, hospital matron as well as the sister in charge Opportunistic infections department and TB. The application stated the duration that the practicum was going to take and the period being six weeks. It also stated the purpose of the practicum that it intended to provide community mobilization to people with TB and to people living with HIV and AIDS about the need to prevent TB infections among HIV positive individuals. After a period of three days the researcher got the response which gave a green light to carry out the practicum at the hospital. Like in any other organisation the hospital matron gave some cautions that were to be observed during and after the period of the practicum activity. There are certain codes of conduct that safeguards both the TB and HIV patients and the researcher at the same time. The researcher got advice to desist from any activity or procedures that endanger the lives of patients and other members of the organisation. Any information entrusted to by patients was to be kept in confidence and never to divulge patient/clients HIV status without prior consent from the client/patient concerned. The matron then went on to introduce the researcher to the hospital geography and orientation to same departments which included the hospital wards, the pharmacy, the information department and the opportunistic infections department and TB clinic among others. Later the researcher was introduced to the sister in charge opportunistic infections department and TB clinic. The sister in charge took the opportunity to explain the routine procedures of the department like pre, post test and adherence counseling, ART initiation, registration of new clients/patients as well as TB screening and notification. Another application for permission was forwarded to the District Adminstrator for Kwekwe and to the National AIDS Council coordinator to seek for permission to enter the community. The department staff was also introduced to the researcher. The sister in charge became the practicum supervisor, four OI trained nurses and five primary care counselors. Duties roles and responsibilities of each were explained and orientation to registers, TB cards and other relevant stationary of the department was done. There is room one where all the counseling sessions are carried out. In

room number seven that is where ART initiation, change of regiments, reviews and resupply of medications takes place, and the outer open space where TB and opportunistic clinic are held for infection control reasons. The challenges and achievements that the organisation was having were also discussed. The challenges included the emergence of drug resistant TB and also multi drug resistant TB common among HIV patients and whose diagnosis and treatment are not easy due to lack of resources. The hospital diagnos TB per GeneXpert for drug resistance which does not qualify patients for TB drug resistance treatment. Confirmatory tests are required whose results take months to get back to the hospital, thereby increasing the risk of spread of that form of TB due to delay in accessing treatment. The practicum supervisor led the researcher to the hall in the outpatients where clients were gathered following mobilization by researcher through help by TB coordinators in the area. Notices were put in public places to call for a meeting on mobilisaton of community on TB prevention among HIV positive individuals. It was at this juncture that the sister in charge introduced the researcher to the clients/patients as a new member attached to the organisation for six weeks. Arrangements were made on when and how to start the practicum,a program was set which covers six weeks.

3:3 STUDY POPULATION A target population is defined as the population under study, The population generalize the research findings (Talbot 1995) Where as the target population for this practicum shall be people living with HIV and TB infection accessing treatment at Kwekwe general hospital.

3:3; 1 SAMPLING PROCEDURE

Sampling is selecting some of the elements of the population so that the researchers can draw conclusions about the entire population. The population in research methodology is the total group of the subjects that need to be assessed if the views of everyone in a particular situation are to be measured, Grein et al (2004). In this practicum, the sample population was consisting of people living with HIV and TB aged between twenty to fifty years. The simple random sampling method was used where a total number of 30 participants were used. Three rooms were used to select the sample. Room two which is used for counseling, room seven which is used for antiretroviral therapy initiation and room eight where review and registration of

patients is done. Each room had about ten cards whereby every third client to enter the room was selected in the sample.

3:4 NEED ASSESSMENT AND DESK STUDY

The exercise comprised of a number of activities. These activities included focus group discussions FGDs, Observations, interviews and exit interviews among others.

3:4, 1 FOCUS GROUP DISCUSSIONS (FGDs)

The thirty participants who finally got the chance to be included in the sample were further sub divided into three groups comprising of ten participants in each group. In each the ratio of men to women was 2:1,aged between twenty and fifty years. These clients /patients were among those on antiretroviral therapy, TB treatment or both age range 20 to 50 both male and female. The first ten participants discussed about the factors behind the increase of TB among HIV positive individuals and their experiences. . The information required to assess their knowledge, find out about their perceptions, attitudes, beliefs (religious/traditional), myth and misconceptions that they have towards TB and HIV. The discussion also seeked to find information about forms of shelter and relationship to occurrence of TB and how other factors like impaired immune system could be associated to TB infection by the clients. The researcher also intended to find out from the participants about the dangers that may arise when someone chooses to delay or default TB and HIV treatment. The discussion dovetailed to elicit information on whether from participants view TB in HIV could be prevented. It further went on to find about what they thought the factors that cause TB in HIV could be. . The practicum field supervisor was observing while the researcher was asking questions and conducting the discussion. Information was recorded as the participants were saying out their views and concerns. This was meant to craft a way forward to mobilize the community basing on what the discussion revealed. At the end of the session gathered data was then compiled to form the basis upon which the objectives were crafted. The session took about one and a half hours. Future appointments were arranged, concluding remarks were given by the sister in charge followed by dismissal.

3:4, 2 OBSERVATIONS OF COUNSELLING SESSIONS

The second phase was to observe the primary care counselors undertaking routine adherence counseling sessions to the second group of ten participants. This was carried out when the researcher and the supervisor sat quietly observing how the primary care counselor went about

doing the counseling. The counselor gave information about HIV/AIDS and TB. The discussion included issues that aim at equipping clients/patients with knowledge about the possibility of contracting TB as an opportunistic infection. The researcher observed the way information was being delivered to the clients /patients. Non verbal cues were also being noted. The most important aspects that the primary care counselor was emphasizing to the participants were also jotted down. The use of teaching aids like charts, pamphlets and real objects like examples of drugs used to treat TB were demonstrated as clients took their drugs on DOT. The advantages of taking treatment whist a health worker was observing were given to the participants. Signing of the DOT card was also demonstrated to clients. Review dates ,adherence to treatment and to appointments were discussed and were said to promote treatment success. The nurse explained that treatment for both TB and HIV is available and is for free at the hospital. As a way of reinforcing the lessons each of the participants was given some written pamphlets with pictures that showed an individual with a cough and aerosols spreading in the air. At the end of the session a recap with participants to ensure understanding was done. Question and answer time was provided with all questions being answered correctly myth and misconceptions identified and corrected. Attitudes towards TB and HIV were also displayed. Most feared was stigma and discrimination which was making it difficult for people with HIV and TB to access health services freely. Other factors to do with problems in accessing health services were religious and traditional according to participants views. Some participants pointed out knowledge deficit as a major obstacle ,torwards accessing care and treatment. Participants highlighted that some health care givers do not provide correct information on TB and HIV.

3:4, 3 EXIT INTERVIEW Not all participants who were present on the first day managed to turn up for exit interview. A total of three participants could not make it due to unknown circumstances. Five female participants and two male participant managed to report for the interview. A set of questions based on the information given about HIV and TB sought to find out on what the participants had learnt about. The exit interview was conducted in such a way that one participant would be interviewed while others would be outside and a different exit was used to avoid the possibility of sharing the questions. t. The interview went on while a score sheet was filled for each participant. The participant was first asked the language that she or he was comfortable to be interviewed in.

Focus Group discussions FDGs, observations and exit interviews which were conducted by the researcher formed the basis upon which health education talks were derived. There were

knowledge gaps, myths, misconceptions, beliefs and practices that were identified. These were addressed through health education mobilization time. Health education was conducted on the fourth week of the practicum as per activity schedule. All the chosen participants managed to turn up for the health talks. As usual the health education talks are being done first thing every morning from Monday to Friday. The identified problems were mostly to do with lack of knowledge in HIV and TB prevention, stigma and discrimination, treatment regiments for TB and HIV as well as disclosure of HIV status to significant others. These topics were given to each speaker, the researcher, the primary care counselor and one of the senior nurses of the department. The researcher gave health education on the importance of disclosing HIV status to significant others and how it reduces stigma. The clients were taught about drug adherence and how it helps in reduction of drug resistance and prevent treatment failure the likes of multi drug resistant TB Participants also learnt about the mode of action, side effects of ARVS and TB drugs At last the primary care counselor took the opportunity to explain why it is very important to use condoms even when both people are HIV positive. It was explained to the participants that there are different strands of HIV which infect people and this is why even when both partners are HIV positive they still need to use condoms to prevent further exposure to other viral strands. It was clearly explained that while other strands may respond to the treatment the patient may be on. The other type may show signs of drug resistance. This may promote the use of other very expensive ARVs which may not be locally available. It was further explained that preventing oneself from HIV infection is protecting self from TB as it is one of the factors that impair immune system and predisposes people to TB.

Questions were asked on all matters that were under discussion and answers were provided. Participants who had indicated that they were having difficulties with issues of stigma were taken note of and follow up visits were arranged.

3.4:4 FOLLOW UP VISIT ON INDIVIDUALS IN COMMUNITY

Two patients needed follow up to their homes in the community ,one had multi drug resistant TB and required family education on preventing spread to other family members. The visit was on a Wednesday and the TB and HIV vehicle donated by Global fund was use, fuel was bought by the hospital using hospital services fund. The family was in Mbizo section five. The family was ready for the TB and HIV team as the visit was planned. The family welcomed the team and introductions were made .Health education was mainly on good family hygiene, good cough hygiene, and hand washing techniques were taught. Recommendations were made that the client sleeps alone during the first two months of MDR TB treatment to prevent spread to other family members .Questions were asked and answers provided. The team thanked the family and invited them to come whenever need arises. The family also appreciated the visit and promised to come if need arises. The team left for Mbizo section 18 where the client and family were not found. neighbours said the husband had gone to the mine and the wife had gone to their rural home. Efforts to conduct them were fruitless .The report was forwarded to the TB coordinators for them to make a follow up on the family.

3:5 CONCLUSSION
The experience that the researcher got from this particular mobilisation practicum opened some avenues for further studies. It was realized that there are factors that stand in the way but of different backgrounds.The communities have to be continuously educated to prevent tuberculosis among TB and HIV individuals at Kwekwe hospital.