"They do not see us as one of them": a qualitative exploration of mentor mothers' working relationships with healthcare workers in rural North-Central Nigeria

Nadia A Sam-Agudu, Angela Odiachi, Miriam J Bathnna, Chinazom N Ekwueme, Gift Nwanne, Emilia N Iwu, Llewellyn J Cornelius, Nadia A Sam-Agudu, Angela Odiachi, Miriam J Bathnna, Chinazom N Ekwueme, Gift Nwanne, Emilia N Iwu, Llewellyn J Cornelius

Abstract

Background: In HIV programs, mentor mothers (MMs) are women living with HIV who provide peer support for other women to navigate HIV care, especially in the prevention of mother-to-child transmission of HIV (PMTCT). Nigeria has significant PMTCT program gaps, and in this resource-constrained setting, lay health workers such as MMs serve as task shifting resources for formal healthcare workers and facility-community liaisons for their clients. However, challenging work conditions including tenuous working relationships with healthcare workers can reduce MMs' impact on PMTCT outcomes. This study explores the experiences and opinions of MMs with respect to their work conditions and relationships with healthcare workers.

Methods: This study was nested in the prospective two-arm Mother Mentor (MoMent) study, which evaluated structured peer support in PMTCT. Thirty-six out of the 38 MMs who were ever engaged in the MoMent study were interviewed in seven focus group discussions, which focused on MM workload and stipends, scope of work, and relationships with healthcare workers. English and English-translated Hausa-language transcripts were manually analyzed by theme and content in a grounded theory approach.

Results: Both intervention and control-arm MMs reported positive and negative relationships with healthcare workers, modulated by individual healthcare worker and structural factors. Issues with facility-level scope of work, workplace hierarchy, exclusivism and stigma/discrimination from healthcare workers were discussed. MMs identified clarification, formalization, and health system integration of their roles and services as potential mitigations to tenuous relationships with healthcare workers and challenging working conditions.

Conclusions: MMs function in multiple roles, as task shifting resources, lay community health workers, and peer counselors. MMs need a more formalized, well-defined niche that is fully integrated into the health system and is responsive to their needs. Additionally, the definition and formalization of MM roles have to take healthcare worker orientation, sensitization, and acceptability into consideration.

Trial registration: Clinicaltrials.gov number NCT01936753 , registered September 3, 2013.

Keywords: Expert mother; HIV; Human resources for health; Mentor mother; Nigeria; PMTCT; Peer support; Task shifting.

Conflict of interest statement

Ethics approval and consent to participate

The study was approved by the Nigerian National Health Research Ethics Committee, the Ethics Review Committee of the World Health Organization, and the Institutional Review Boards of the University of Maryland Baltimore and the University of Georgia Athens. Written informed consent was obtained from all study participants.

Consent for publication

Not applicable

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
Core emerging themes from qualitative data analysis

References

    1. Baek C, Mathambo V, Mkhize S, Friedman I, Apicella L, Rutenberg N. Key findings from an evaluation of the mothers2mothers program in KwaZulu-Natal, South Africa, Horizons Final Report. Washington DC: Population Council; 2007.
    1. Futterman D, Shea J, Besser M, Stafford S, Desmond K, Comulada W, et al. Mamekhaya: a pilot study combining a cognitive-behavioral intervention and mentor mothers with PMTCT services in South Africa. AIDS Care. 2010;22(9):1093–1100. doi: 10.1080/09540121003600352.
    1. McColl K. Mentor mothers to prevent mother-to-child transmission of HIV. BMJ. 2012;344:e1590. doi: 10.1136/bmj.e1590.
    1. Cataldo F, Sam-Agudu NA, Phiri S, Shumba B, Cornelius LJ, Foster G. The roles of expert mothers engaged in prevention of mother-to-child transmission (PMTCT) programs: a commentary on the INSPIRE studies in Malawi, Nigeria, and Zimbabwe. J Acquir Immune Defic Syndr. 2017;75(Suppl 2):S224–SS32. doi: 10.1097/QAI.0000000000001375.
    1. Rotheram-Borus M, Richter L, Van-Rooyen H, van-Heerden A, Tomlinson M, Stein A, et al. Project Masihambisane: a cluster randomised controlled trial with peer mentors to improve outcomes for pregnant mothers living with HIV. Trials. 2011;12:2. doi: 10.1186/1745-6215-12-2.
    1. Schneider H, Lehmann U. Lay health workers and HIV programmes: implications for health systems. AIDS Care. 2010;22(Suppl 1):60–67. doi: 10.1080/09540120903483042.
    1. Flynn DE, Johnson C, Sands A, Wong V, Figueroa C, Baggaley R. Can trained lay providers perform HIV testing services? A review of national HIV testing policies. BMC Res Notes. 2017;10(1):20. doi: 10.1186/s13104-016-2339-1.
    1. Lewin S, Munabi-Babigumira S, Glenton C, Daniels K, Bosch-Capblanch X, van Wyk BE, et al. Lay health workers in primary and community health care for maternal and child health and the management of infectious diseases. Cochrane Database Syst Rev. 2010;(3):Cd004015. 10.1002/14651858.CD004015.pub3.
    1. Glenton C, Colvin CJ, Carlsen B, Swartz A, Lewin S, Noyes J, et al. Barriers and facilitators to the implementation of lay health worker programmes to improve access to maternal and child health: qualitative evidence synthesis. Cochrane Database Syst Rev. 2013;(10):Cd010414. 10.1002/14651858.CD010414.pub2.
    1. Hermann K, Van Damme W, Pariyo GW, Schouten E, Assefa Y, Cirera A, et al. Community health workers for ART in sub-Saharan Africa: learning from experience--capitalizing on new opportunities. Hum Resour Health. 2009;7:31. doi: 10.1186/1478-4491-7-31.
    1. Mwai GW, Mburu G, Torpey K, Frost P, Ford N, Seeley J. Role and outcomes of community health workers in HIV care in sub-Saharan Africa: a systematic review. J Int AIDS Soc. 2013;16(1):18586. doi: 10.7448/IAS.16.1.18586.
    1. Dapaah J, Moyer E. Dilemmas of patient expertise: people living with HIV as peer educators in a Ghanaian hospital. Ghana Stud. 2013;15:195–221.
    1. Schneider H, Hlophe H, van Rensburg D. Community health workers and the response to HIV/AIDS in South Africa: tensions and prospects. Health Policy Plan. 2008;23(3):179–187. doi: 10.1093/heapol/czn006.
    1. Yakam JC, Gruenais ME. Involving new actors to achieve ART scaling-up: difficulties in an HIV/AIDS counselling and testing centre in Cameroon. Int Nurs Rev. 2009;56(1):50–57. doi: 10.1111/j.1466-7657.2008.00680.x.
    1. Dlamini-Simelane T, Moyer E. Task shifting or shifting care practices? The impact of task shifting on patients’ experiences and health care arrangements in Swaziland. BMC Health Serv Res. 2017;17(1):20. doi: 10.1186/s12913-016-1960-y.
    1. Cataldo F, Kielmann K, Kielmann T, Mburu G, Musheke M. ‘Deep down in their heart, they wish they could be given some incentives’: a qualitative study on the changing roles and relations of care among home-based caregivers in Zambia. BMC Health Serv Res. 2015;15:36. doi: 10.1186/s12913-015-0685-7.
    1. World Health Organization . Task shifting : rational redistribution of tasks among health workforce teams : global recommendations and guidelines. 2008.
    1. Iwu EN, Holzemer WL. Task shifting of HIV management from doctors to nurses in Africa: clinical outcomes and evidence on nurse self-efficacy and job satisfaction. AIDS Care. 2014;26(1):42–52. doi: 10.1080/09540121.2013.793278.
    1. Kredo T, Adeniyi FB, Bateganya M, Pienaar ED. Task shifting from doctors to non-doctors for initiation and maintenance of antiretroviral therapy. Cochrane Database Syst Rev. 2014;(7):Cd007331. 10.1002/14651858.CD007331.pub3.
    1. Callaghan M, Ford N, Schneider H. A systematic review of task-shifting for HIV treatment and care in Africa. Hum Resour Health. 2010;8:8. doi: 10.1186/1478-4491-8-8.
    1. UNAIDS . HIV estimates with uncertainty bounds 1990-2016. 2017.
    1. UNAIDS . On the fast track to an AIDS Free Generation: the incredible journey of the global plan towards the elimination of new hiv infections among children by 2015 and keeping their mothers alive. 2016.
    1. Nigeria National Agency for the Control of AIDS . Fact sheet: prevention of mother-to-child transmission of HIV (PMTCT), Nigeria, 2016. 2016.
    1. Sam-Agudu NA, Ramadhani HO, Isah C, Anaba U, Erekaha S, Fan-Osuala C, et al. The impact of structured mentor mother programs on 6-month postpartum retention and viral suppression among HIV-positive women in rural Nigeria: a prospective paired cohort study. J Acquir Immune Defic Syndr. 2017;75(Suppl 2):S173–SS81. doi: 10.1097/QAI.0000000000001346.
    1. Sam-Agudu NA, Ramadhani HO, Isah C, Erekaha S, Fan-Osuala C, Anaba U, et al. The impact of structured mentor mother programs on presentation for early infant diagnosis testing in rural North-Central Nigeria: a prospective paired cohort study. J Acquir Immune Defic Syndr. 2017;75(Suppl 2):S182–S1S9. doi: 10.1097/QAI.0000000000001345.
    1. Rotheram-Borus MJ, Richter LM, van Heerden A, van Rooyen H, Tomlinson M, Harwood JM, et al. A cluster randomized controlled trial evaluating the efficacy of peer mentors to support South African women living with HIV and their infants. PLoS One. 2014;9(1):e84867. doi: 10.1371/journal.pone.0084867.
    1. Shroufi A, Mafara E, Saint-Sauveur JF, Taziwa F, Vinoles MC. Mother to mother (M2M) peer support for women in prevention of mother to child transmission (PMTCT) programmes: a qualitative study. PLoS One. 2013;8(6):e64717. doi: 10.1371/journal.pone.0064717.
    1. Richter L, Rotheram-Borus MJ, Van Heerden A, Stein A, Tomlinson M, Harwood JM, et al. Pregnant women living with HIV (WLH) supported at clinics by peer WLH: a cluster randomized controlled trial. AIDS Behav. 2014;18(4):706–715. doi: 10.1007/s10461-014-0694-2.
    1. The Ethiopia Network for HIV/AIDS Treatment Care and Support Program . The role of mother mentors in supporting HIV-positive mothers. 2014.
    1. Phiri S, Tweya H, van Lettow M, Rosenberg NE, Trapence C, Kapito-Tembo A, et al. Impact of facility- and community-based peer support models on maternal uptake and retention in Malawi's option B+ HIV prevention of mother-to-child transmission program: a 3-arm cluster randomized controlled trial (PURE Malawi) J Acquir Immune Defic Syndr. 2017;75(Suppl 2):S140–S1s8. doi: 10.1097/QAI.0000000000001357.
    1. Blattner W, Dakum P, Osotimehin B, Nasidi A, Abimiku A. Public health aspects of HIV/AIDS – Nigeria and West Africa. In: Celentano D, Beyrer C, editors. Public health aspects of HIV/AIDS in low and middle income countries. New York: Springer-Verlag New York; 2009. pp. 217–251.
    1. Federal Ministry of Health Nigeria . Task shifting/task-sharing policy for essential health care services in Nigeria. 2014.
    1. Kyakuwa M, Hardon A, Goldstein Z. “The adopted children of ART”: expert clients and role tensions in ART provision in Uganda. Med Anthropol. 2012;31(2):149–161. doi: 10.1080/01459740.2011.603399.
    1. Zachariah R, Ford N, Philips M, Lynch S, Massaquoi M, Janssens V, et al. Task shifting in HIV/AIDS: opportunities, challenges and proposed actions for sub-Saharan Africa. Trans R Soc Trop Med Hyg. 2009;103(6):549–558. doi: 10.1016/j.trstmh.2008.09.019.
    1. Sam-Agudu NA, Cornelius LJ, Okundaye JN, Adeyemi OA, Isah HO, Wiwa OM, et al. The impact of mentor mother programs on PMTCT service uptake and retention-in-care at primary health care facilities in Nigeria: a prospective cohort study (MoMent Nigeria) J Acquir Immune Defic Syndr. 2014;67(Suppl 2):S132–S138. doi: 10.1097/QAI.0000000000000331.
    1. Manji-Obadiah G, Saunders E, Fan-Osuala C, Nta I, Sam-Agudu N. Client evaluation of peer counselor performance in a rural PMTCT program in Nigeria. Washington DC: 8th Consortium of Universties in Global Health Conference; 2017.
    1. Birt L, Scott S, Cavers D, Campbell C, Walter F. Member checking: a tool to enhance trustworthiness or merely a nod to validation? Qual Health Res. 2016;26(13):1802–11.
    1. Glaser B, Strauss A. The discovery of grounded theory: strategies for qualitative research. Chicago: Aldine Transaction Publishers; 2009.
    1. Feyissa GT, Abebe L, Girma E, Woldie M. Stigma and discrimination against people living with HIV by healthcare providers, Southwest Ethiopia. BMC Public Health. 2012;12:522. doi: 10.1186/1471-2458-12-522.
    1. Vorasane S, Jimba M, Kikuchi K, Yasuoka J, Nanishi K, Durham J, et al. An investigation of stigmatizing attitudes towards people living with HIV/AIDS by doctors and nurses in Vientiane, Lao PDR. BMC Health Serv Res. 2017;17(1):125. doi: 10.1186/s12913-017-2068-8.
    1. Reis C, Heisler M, Amowitz LL, Moreland RS, Mafeni JO, Anyamele C, et al. Discriminatory attitudes and practices by health workers toward patients with HIV/AIDS in Nigeria. PLoS Med. 2005;2(8):e246. doi: 10.1371/journal.pmed.0020246.
    1. Dako-Gyeke M, Dako-Gyeke P, Asampong E. Experiences of stigmatization and discrimination in accessing health services: voices of persons living with HIV in Ghana. Soc Work Health Care. 2015;54(3):269–285. doi: 10.1080/00981389.2015.1005268.
    1. Wynn A, Rotheram-Borus MJ, Leibowitz AA, Weichle T, Roux IL, Tomlinson M. Mentor mothers program improved child health outcomes at a relatively low cost in South Africa. Health Aff (Millwood) 2017;36(11):1947–1955. doi: 10.1377/hlthaff.2017.0553.
    1. Sam-Agudu N, Cornelius LJ, Okundaye JN, Adeyemi OA, Isah C, Isah HO, et al. The MoMent study: acceptability of mentor mothers as a PMTCT intervention in rural North-Central Nigeria. Lusaka: 8th INTEREST Workshop; 2014.
    1. Schneider H, Okello D, Lehmann U. The global pendulum swing towards community health workers in low- and middle-income countries: a scoping review of trends, geographical distribution and programmatic orientations, 2005 to 2014. Hum Resour Health. 2016;14(1):65. doi: 10.1186/s12960-016-0163-2.

Source: PubMed

Sponsors and Collaborators

Medical Conditions

Drug Interventions

3
Subscribe