practicum chapter 3 n
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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 consentfrom 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
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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 treatmentare 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
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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 beprevented. 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
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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 pamphletswith 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 TBand 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 whileothers 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
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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, sideeffects 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.
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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 HIVteam 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.