Motivations for entering and remaining in volunteer service: findings from a mixed-method survey among HIV caregivers in Zambia.

BACKGROUND: A high burden of HIV in many sub-Saharan African countries has triggered renewed interest in volunteer-based community health programmes as a way to support treatment roll-out and to deliver services to children orphaned due to HIV. This study was undertaken as an evaluation of a USAID project implemented by a consortium of 7 NGOs operating in 52 Zambian districts. We aimed to examine motivations for becoming volunteer caregivers, experiences in service and commitment to continue volunteering in the future. METHODS: A mixed-method survey approach was adopted incorporating close- and open-ended questions. District selection (3 of 52) was purposive, based on representation of urban, peri-urban and rural volunteers from a mix of the consortium's NGO affiliates. Individual volunteer recruitment was achieved via group information sessions and opportunistic sampling was used to reach a quota (~300) per study district. All participants provided written informed consent. RESULTS: A total of 758 eligible caregivers were surveyed. Through parallel analyses of different data types and cross-over mixed analyses, we found shifting patterns in motivations across question type, question topic and question timing. In relation to motivations for entering service, responses to both open- and close-ended questions highlighted the importance of value-oriented functions and higher order social aspirations such as "helping society" or "humanity". However, 70% of participants also agreed to at least one close-ended economic motivation statement and nearly a quarter (23%) agreed to all four. Illustrating economic need, as well as economic motivation, over half (53%) the study respondents agreed that they had become a volunteer because they needed help from the project. Volunteers with lower and mid-level standard-of-living scores were significantly more likely to agree with economic motivation statements. CONCLUSIONS: Reliance by national and international health programmes on volunteer workforces is rooted in the assumption that volunteers are less costly and thus more sustainable than maintaining a professional cadre of community health workers. Understanding individuals' motivations for entering and remaining in volunteer service is therefore critical for programme planners and policy makers. This study demonstrated that volunteers had complex motivations for entering and continuing service, including "helping" and other pro-social values, but also manifest expectations of and need for material support. These findings contribute to evidence in support of various reforms needed to strengthen the viability and sustainability of volunteer-dependent services including the need to acknowledge and plan for the economic vulnerability of so-called volunteer recruits.

Behavior change pathways to voluntary medical male circumcision: narrative interviews with circumcision clients in Zambia.

As an HIV prevention strategy, the scale-up of voluntary medical male circumcision (VMMC) is underway in 14 countries in Africa. For prevention impact, these countries must perform millions of circumcisions in adolescent and adult men before 2015. Although acceptability of VMMC in the region is well documented and service delivery efforts have proven successful, countries remain behind in meeting circumcision targets. A better understanding of men's VMMC-seeking behaviors and experiences is needed to improve communication and interventions to accelerate uptake. To this end, we conducted semi-structured interviews with 40 clients waiting for surgical circumcision at clinics in Zambia. Based on Stages of Change behavioral theory, men were asked to recount how they learned about adult circumcision, why they decided it was right for them, what they feared most, how they overcame their fears, and the steps they took to make it to the clinic that day. Thematic analysis across all cases allowed us to identify key behavior change triggers while within-case analysis elucidated variants of one predominant behavior change pattern. Major stages included: awareness and critical belief adjustment, norming pressures and personalization of advantages, a period of fear management and finally VMMC-seeking. Qualitative comparative analysis of ever-married and never-married men revealed important similarities and differences between the two groups. Unprompted, 17 of the men described one to four failed prior attempts to become circumcised. Experienced more frequently by older men, failed VMMC attempts were often due to service-side barriers. Findings highlight intervention opportunities to increase VMMC uptake. Reaching uncircumcised men via close male friends and female sex partners and tailoring messages to stage-specific concerns and needs would help accelerate men's movement through the behavior change process. Expanding service access is also needed to meet current demand. Improving clinic efficiencies and introducing time-saving procedures and advance scheduling options should be considered.

Self-care production experiences in elderly African Americans with hypertension and cognitive difficulty.

PURPOSE: The purpose of this qualitative descriptive study was to explore self-care production experiences in older African Americans who, despite some cognitive dysfunction, were able to produce hypertension-related self-care behaviors or blood pressure control successfully. DATA SOURCES: Participants were 10 urban, community-dwelling older African Americans, 60-89 years of age, living in a Midwest region of the United States. A semi-structured interview was conducted in participants homes' using Kvale's "conversational discourse" approach. Oral recordings were transcribed and analyzed for themes and codes. CONCLUSIONS: Elders' experiences with the production of self-care were characterized by three themes: preparation, monitoring, and evaluation. Self-care production was found to be cognitively challenging consistent with the finding that 60% of the participants had difficulty with a cognitive task requiring complex cognitive skills. This finding may explain why the production of self-care became a social phenomenon in which elders demonstrated resourcefulness in seeking assistance from surrounding support systems. IMPLICATIONS FOR PRACTICE: Nurse practitioners can support better health outcomes in older adults with hypertension by using valid and reliable measures for assessing complex cognitive skills, assessing individuals' progress in self-care production, and identifying individuals' use of social and professional supports to produce self-care.

Integrating HIV clinical services into primary health care in Rwanda: a measure of quantitative effects.

BACKGROUND: With the intensive scale-up of care and treatment for HIV/AIDS in developing countries, some fear that intensified attention to HIV programs may overwhelm health care systems and lead to declines in delivery of other primary health care. Few data exist that confirm negative or positive synergies on health care provision generally resulting from HIV-dedicated programs. METHODS: Using a retrospective observational design we compare aggregate service data in Rwandan health facilities before and after the introduction of HIV care on selected measures of primary health care. The study tests the hypothesis that non-HIV care does not decrease after the introduction of basic HIV care. FINDINGS: Overall, no declines were observed in reproductive health services, services for children, laboratory tests, and curative care. Statistically significant increases were found in utilization and provision of some preventive services. Multivariate regression, including introduction of HIV care and two important health care financing initiatives in Rwanda, revealed positive associations of all with observed increases. Introduction of HIV services was especially associated with increases in reproductive health. While hospitalization rates increased for the whole sample, declines were observed at health facilities that offered basic HIV care plus highly active antiretroviral therapy. INTERPRETATION: Our results partially counter fears that HIV programs are producing adverse effects in non-HIV service delivery. Rather than leading to declines in other primary health care delivery, our findings suggest that the integration of HIV clinical services may contribute to increases.