Support provided by outreach team leaders to caregivers of HIV/AIDS orphans in the North-West Province of South Africa

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Molato, Salaminah S. Moloko-Phiri, Magdalena P. Koen, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4296065/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 31 Aug, 2024 Read the published version in BMC Nursing → Version 1 posted 10 You are reading this latest preprint version Abstract Background The human immunodeficiency virus (HIV) and acquired immunodeficiency deficiency syndrome (AIDS) epidemic have left an overwhelming impact on communities worldwide, particularly in Sub-Saharan Africa, where its effects on family structures are particularly pronounced. Caregivers of children orphaned by HIV/AIDS encounter challenges in fulfilling their caring duties. Consequently, they rely on the outreach team leaders (OTLs) for support to care for HIV/AIDS orphans. Aim This study aimed to explore and describe support provided by OTLs to caregivers of children orphaned by HIV/AIDS in the North West Province of South Africa. Methods The exploratory, descriptive, and contextual design was used to realize the objectives of this study. The study was conducted in five local municipalities in the Ngaka Modiri Molema district of the North West Province of South Africa. Ward-based outreach nurses were participants in the study. Semi-structured focus group interviews were used for data collection. Thematic analysis was used to analyze data. Throughout the study, ethical principles were adhered to. The study also adhered to four trustworthiness principles: credibility, confirmability, transferability, and dependability. Results Three main themes emerged from this study: the conduction of home visits to caregivers of HIV/AIDS orphans, the coordination of a multidisciplinary team for support, and the facilitation of support groups. Conclusions The study revealed support provided by OTLs to the caregivers of children orphaned by HIV/AIDS. Caregivers benefitted from the support provided and, therefore, experienced less stigma. Moreover, discrimination was reduced, disclosure was done on time, and medication adherence improved. Caregivers children orphaned by HIV/AIDS outreach team leaders support Introduction Many children are left as orphans without help or resources after their parents pass away from Human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) [ 1 ] This incident has put them at risk for hunger, psychological distress, and impoverishment [ 2 ]. After the death of the parents, orphaned children are usually cared for by primary caregivers [ 3 ]. Previous studies revealed that caregivers of HIV/AIDS orphans face challenges that include a lack of support from social services and family, stigma, and discrimination when caring for HIV/AIDS orphans [ 4 , 5 ]. Due to the high rate of unemployment, caregivers are unable to provide orphaned children with basic needs such as access to necessities like food and clothing [ 6 , 7 ]. To help caregivers with some of the financial challenges involved in raising orphans, the South African government offers social security in the form of Foster Care or Child Support. Notwithstanding the restricted financial resources, poverty continues to be a significant issue that impacts orphaned children both before and after a parent passes away [ 6 ]. With regards to the older caregivers, caregiving is not easy due to age they face many difficulties that include the execution of duties without undergoing proper training for caregiving. The authors further claimed that the challenges that older caregivers face predispose them to burdens that affect their physical, and psychological well-being [ 8 , 9 ]. Furthermore, grandparent caregivers often present with health challenges, such as poorer emotional well-being and declining psychological health, because of stressors arising from caring for their grandchildren [ 10 , 11 ]. Consequently, the stress of providing care exposes caregivers to long-term illnesses that make it difficult for them to perform their daily caregiving responsibilities [ 12 ]. Given these challenges, the South African (S.A.) government introduced primary health care (PHC) re-engineering strategy to promote health by providing services to society at their respective homes [ 13 ]. The PHC re-engineering model comprises ward-based primary health care outreach teams (WBPHCOT), district specialist teams, and school health teams [ 14 ]. The author further indicates that this strategy represents an attempt to formalize, standardize, and integrate community-based services into the PHC system. The WBPHCOTs act as a link between healthcare facilities and the communities they serve [ 15 , 16 ]. This can be particularly helpful in rural places where people must travel great distances for medical care and when communities are underserved and disadvantaged. The purpose of PHC re-engineering is to establish a district health system focused on solving society's most pressing health needs through PHC teams [ 17 ]. Each ward has a WBPHCOT led by a professional nurse commonly known as an outreach team leader (OTL). In the South African setting, the OTLs are considered community health nurses because they provide health education, encourage behavioural changes that empower people to take charge of their health, and promote health within the community [ 18 , 19 , 20 ]. The activities performed by OTLs include household and individual assessments, identification of problems, provision of interventions, and referrals [ 17 ]. These routine visits enable OTLs to conduct different assessments of the individuals they visit. The OTLs conduct assessments on caregivers of HIV/AIDS orphans; they intervene and provide the needed support. Existing literature has highlighted the support provided by community health workers (CHWs) as members of WBPHCOTs who work closely with OTLs [ 21 , 22 ]. In the United States, CHWs play an essential role in the treatment of diseases like hypertension, diabetes, HIV, cancer screening, and lowering the risk of cardiovascular disease [ 23 , 24 , 25 , 26 ]. In South Africa, CHWs provide the support that contributes to the successful implementation of the human immunodeficiency virus (HIV) program [ 27 , 28 ]. Up to now, the support provided by OTLs in the North West Province (NWP) of South Africa (SA) remains unknown regardless of the challenges faced as reported by existing literature [ 29 ]. Therefore, the researchers found it necessary to explore and describe the support provided by outreach team leaders in the North West province of South Africa. This study addresses the third objective of the main (PhD) study which aims to develop health promotion strategies to improve the health and well-being of caregivers of HIV/AIDS orphans in NWP of SA. Exploration of the support provided by OTLs may assist in formulating recommendations that focus on mitigating circumstances surrounding caregivers of HIV/AIDS orphans. Furthermore, the findings of this study might assist in developing health promotion strategies as the main objective of the study. Materials and Methods 2.1 Aim This study aimed to explore and describe support provided by WBPHCOT leaders to the caregivers of HIV/AIDS orphans in the NWP of SA. 2.2 Research design This study used the qualitative exploratory, descriptive design to explore and describe the support provided by OTLs to the caregivers of HIV/AIDS orphans in the NWP of SA. Through qualitative research, researchers were able to get insight into the meaning that people attribute to their experiences by getting access to research participants' thoughts and feelings [30]. Exploratory research design was used to better understand the nature of the problem because little was known regarding the phenomenon [31,32]. Descriptive research aims to shed light on current issues or problems through a data collection process that allows them to be fully descriptive and go into detail about the phenomena [33]. Moreover, the descriptive research design was used to capture the most authentic and accurate description of data collected to describe the support provided by OTLs to the caregivers of HIV/AIDS orphans in Ngaka Modiri Molema district in the NWP of SA. concerning contextual research design, we interacted with the caregivers in the village in which they reside [34]. Furthermore, the environment where data was collected was free from manipulation natural surroundings entails that the environment is free from manipulation [35]. 2.3 Study Setting The study was conducted in five local municipalities of the Ngaka Modiri Molema District of the NWP of SA. The local municipalities where the study was conducted were Mahikeng, Ratlou, Ramotshere Moiloa, Ditsobotla, and Tswaing. The district shares an international border with Botswana and is located at the center of the province. 2.4 Population and Sampling The population of the study was OTLs rendering care to the caregivers of HIV/AIDS orphans in Ngaka Modiri Molema District. The OTLs considered eligible for this study were registered nurses with a qualification in community nursing, with or without additional qualification of PHC, and had the experience of at least six months as OTLs. Non-probability purposive sampling was used to sample the OTLs who were eligible to actively participate in the study. Every participant in the target population does not have equal chances because the sample population was chosen in a non-systematic manner [36]. Purposive sampling assisted in selecting participants who shared fundamental information related to the study [37]. 2.5 Data collection Data was collected face-to-face at the local clinics in the Ngaka Modiri Molema district of the NWP. Five (5) focus group sessions were conducted to achieve the objectives of the study. The study used semi-structured focus group discussions to gather information from the OTLs. The interview guide was developed to achieve the objectives of the study. The exploratory question was: What support is provided by OTLs to caregivers of children orphaned by HIV/AIDS in NWP, SA? An audio recorder was used to record the discussions. The discussions lasted for 45-60 minutes. To accomplish the goals of the study, open-ended and brief questions were asked [38]. Field notes were used to capture all activities that unfolded during the discussions to ensure accurate recording of vital information [39]. Interviews were conducted in English and data saturation was reached in focus group number five. 2.6 Data analysis The researcher and independent co-coder used six (6) steps of thematic analysis to analyze data as stipulated by [40]. In terms of familiarisation of data, which is the first step, we have read and re-read the transcripts to familiarize ourselves with the data. The second step of thematic analysis followed was the generation of initial codes [39, 40]. The data was arranged in a methodical and comprehensible manner. After that, we each started coding a transcript on our own. Every text passage that appeared to be pertinent to or directly addressed our study issue was coded as we went through each transcript. After we were done, we reviewed, compared, and adjusted our codes before going on to the remaining transcripts. The data was arranged in a methodical and comprehensible manner. After that, we each started coding a transcript on our own [39, 40]. The quotations that emerged from the interviews were used to cite the findings. Every text passage that appeared to be pertinent to or directly addressed our study issue was coded as we went through each transcript. After we were done, we reviewed, compared, and adjusted our codes before going on to the remaining transcripts [39, 40]. In the third step which is search for themes, when we looked at the codes, it was evident that some of them fit into a theme. The codes were arranged into more general themes after this process, which appeared to address a particular aspect of the research question [39, 40]. Concerning the fourth step which is reviewing themes, this stage involves going over, revising, and expanding on the initial topics that we determined in Step 3 to check coherence. All information related to each theme was compiled. After reading the information related to each theme, we evaluated if the information supported the theme. In terms of the fifth step which was to define themes, we determined the fundamental idea of the theme as well as its main points. This was followed by evaluating each sub-theme in terms of its relevance to the main theme and its interactions with other sub-themes [39, 40]. Writing up was the sixth and the last step, before writing the report, the researcher and co-coder met to check if they had similar themes and sub-themes of the study. 2.7 Trustworthiness Trustworthiness The researcher ensured trustworthiness by adhering to the four principles of trustworthiness namely, credibility, transferability, confirmability, and dependability [41]. Credibility The researchers interacted with the participants for a long time to know their viewpoints. Reflexivity was upheld throughout the data collection, analysis, and interpretation stages to reduce bias in the findings. Numerous methods of gathering data were employed to verify information from multiple perspectives, strengthening the veracity of the descriptions [41]. Transferability A thick description was maintained by fully outlining the research setting, participants, and techniques. To ascertain whether the results would be relevant or transferable to comparable populations or circumstances outside the study context, the sampling techniques that were employed were explained, along with the reasons for participant selection [41]. Confirmability The study's research methods and decision-making processes were recorded. Transparency and traceability were made easier by keeping track of all decisions made throughout the study, including adjustments to methods or analysis [41]. Confirmability The participants were checked to review and confirm the correctness of data to improve confirmability. Biasedness was reduced by discussing interpretations and findings with co-workers or experts [41]. 2.7 Ethical considerations This study was approved by Quality in Nursing and Midwifery (NuMIQ), a research focus in the Faculty of Health Sciences at the North West University (NWU). Ethical clearance was obtained from the NWU Health Research Ethics Committee (NWU-00196-21-A1). The North West Department of Health gave permission to conduct the study. Before conducting the study, participants were given a full explanation regarding the purpose of the study and how the entire process would unfold. The principle of privacy was maintained by placing ‘‘Do not disturb session in progress’’ at the door, and participants’ names were used. The collected data was shared only with the research team. Results A total of 37 professional nurses from five local municipalities voluntarily participated in this study. Both genders were represented although the majority of the participants were females see Table 1 for more details. Table 1: Demographic information of outreach team leaders Variable Category Number Gender Male 4 Female 33 Age in years 30-39 2 40-49 5 50-59 12 60-69 18 Nurses participating in the study per local municipality A B C D E 6 5 5 5 6 Total 37 A total of five semi-structured focus group discussions consisting of five to seven participants were conducted face-to-face see Table 2 for more details regarding the findings of the study. Three main and eleven (10) subthemes were identified in the study. Table 2: Findings of the study Main themes Sub-themes Conduction of home visits to the caregivers of HIV/AIDS orphans. Promotion of medication adherence among children orphaned by HIV/AIDS. Adoption of a Child Strategy. Performance of routine blood and growth monitoring of children orphaned by HIV/AIDS. Provision of physical support to the caregivers of children orphaned by HIV/AIDS during disclosure. Coordination of multidisciplinary team support. Referral to psychologists Referral to social workers Referral to the Dieticians/Nutritionist for nutritional support. Referral to the law enforcement officers for security support. Facilitation of support groups for both caregivers and children orphaned by HIV/AIDS. Adherence clubs. Provision of adolescent-friendly services. Three (3) main themes and ten (10) subthemes were identified in the study. To the researchers' knowledge, this study appeared to be a new contribution to the body of knowledge. The WBPHCOT leaders highlighted different types of support that they provide to caregivers of HIV/AIDS orphans. The support provided by outreach team leaders included conducting home visits to the caregivers of HIV/AIDS orphans, coordinating multidisciplinary teams for support, and facilitating support groups for both caregivers and HIV/AIDS orphans. Each support provided by outreach team leaders was broken into subthemes and is discussed below. Theme 1.1: Conduct home visits at homes of the caregivers of HIV/AIDS orphans The first theme identified was conducting home visits at the homes of caregivers of HIV/AIDS orphans. Four (4) sub-themes emerged from this theme, namely, promotion of medication adherence among HIV/AIDS orphans, adoption of a child strategy, performance of routine blood and growth monitoring of HIV/AIDS orphans, and provision of physical support to the caregivers of HIV/AIDS orphans. 1.1 Sub-theme 1.1: Promotion of medication adherence among HIV/AIDS orphans The promotion of medication adherence emerged as the first sub-theme. Participants used viral load suppression as a tool to determine whether caregivers give HIV/AIDS orphans medication accordingly. For example, if they encounter such cases, they visit them at their homes to conduct assessments to exclude the underlying causes of the viral load. During home visits, the outreach team leaders conduct their assessment to confirm if the caregiver gives the HIV/AIDS orphan medication accordingly. This was expressed as follows: If there is no viral suppression, it is important to check the root cause of why the child's viral load is not giving in to suppression. This case does not require anything special; what we need to do as outreach team leaders is to visit them at home regularly to intensify health education on adherence to ARVs. During the home visit, you check if she is taking treatment on time and swallowing the pills; those critical points will guide you. (Participant 3B) One of the participants reported that they used health education as a weapon to prevent viral suppression and said: We always put more emphasis on health education to avoid reaching the point of poor viral suppression. If there is no viral suppression, we allocate CHWs to start them on the DOT strategy. (Participant 3A) Community health workers (CHWs) are involved in the cases of medication non-adherence to initiate the Directly Observed Therapy (DOT) strategy. The following was echoed. ‘If there is no improvement in medication adherence, we request the CHWs to take over from caregivers by implementing the DOT strategy. The CHWs will be expected to visit the caregivers’ homes every time to ensure that the child takes treatment as s/he should. This strategy helped us a lot to improve adherence among orphaned children. Also this strategy equipped caregivers with more skills because the CHWs involved them during the DOT process.’ (Participant 1D) 1.2 Sub-theme 1.1.2: Adopt a child strategy. Adopt a child strategy was identified as a second subtheme in which outreach team leaders CHWs allowed participants to adopt one HIV/AIDS orphan to monitor whether the caregiver gave the child medication accordingly and to ensure that other aspects of caring were adhered to. The participants expressed the following: ‘There is another strategy introduced by District Health called the Adopt-a-child strategy. About this strategy, the outreach team leaders and CHWs are expected to adopt a child each. We follow them up at home, and this strategy motivates the caregivers to better take care of the HIV/AIDS orphans. When we visit them, we check if the caregiver gives the orphan the correct medication, dose, time, and route.’ (Participant 1C) Another participant added, The adopt-a-child strategy is part of physical support because we assess if the child is growing well, gaining weight, and improving on physical appearance. Adherence has improved; …before the implementation of the Adopt a Child strategy, caregivers did not know how to give medication, and they did not report to us. Currently, caregivers are doing the right thing, and we are following up regularly to ensure they don’t deviate.’ (Participant 2B) Another participant outlined the significance of the strategy. She said: ‘In general, this adopt-a-child strategy capacitates the caregivers of HIV/AIDS orphans with skills because after we adopt a child, we start taking care of them; we even do follow-ups at their respective places to see if they are well and getting treatment correctly. After some time, we handed the child over to CHWs for follow-ups at home to see if the caregivers were doing precisely what we did. The feedback we receive from CHWs is positive that caregivers are doing well in giving medication, there is a positive relationship between orphans and caregivers, and caregiving skills are enhanced.’ (Participant 3E) 1.3 Sub-theme 1.1.3: Performance of routine blood and growth monitoring of HIV/AIDS orphans Monitoring of growth and routine blood checks was identified as a third sub-theme. The outreach team leaders are expected to perform routine blood tests at the respective homes of the caregivers of HIV/AIDS orphans. The following was expressed by one of the participants: ‘After adopting a child, the CHWs will be expected to borrow a weighing scale at the nearest clinic to weigh the child at home. As outreach team leaders, we take routine blood checks at home and attach the child to mentors who are CHWs to ensure that the child regularly gets food and do pill counts to measure adherence.’ (Participant 3C) Another participant expressed the following: ‘If the child does not show any progress, we visit the family every day for at least three months to identify the root cause of the problem. After that, we take routine blood checks to see if there is viral suppression.’ (Participant 1A) Another participant added: ‘We are closely working with CHWs. They have been capacitated with knowledge and skills related to caring. If we come across underweight children during our home visits, we refer them to CHWs to analyze their immunization cards to see whether the child is not malnourished.’ (Participant 2D) 1.4 Sub-theme 1.1.4 Provision of support to caregivers of HIV/AIDS orphans during disclosure Supporting caregivers of HIV/AIDS orphans during disclosure was identified as the fourth subtheme. The participants reported that it was the responsibility of the caregivers to disclose their status to HIV/AIDS orphans. As participants, they avail themselves of support when caregivers disclose their status to HIV/AIDS orphans. The following was verbalized: ‘Nurses do not disclose HIV status, and caregivers are the ones who should do that. As nurses, we avail ourselves just for support. The orphan was already a teenager because she was 15 years old. Luckily, we managed to engage the grandmother because our concern was that the orphan was not receiving treatment. We advised the grandmother to disclose her status to her and to motivate her to start treatment by taking her chronic treatment in her presence so that the child can see that she is not the only one taking treatment alone.’ (Participant 2B) Another participant shared the sentiment of providing support during disclosure. She said: ‘We avail ourselves for support when they disclose HIV status to the orphans. The orphans should not hear about it from people in the village they are not related to. If the child can hear about that from other people, the matter will not sit well with them, and that will cause them to be angry at the person who was supposed to have disclosed the status. ’ (Participant 1B) Another participant verbalized: If I educate the caregivers of HIV/AIDS orphans about the disease of the child, it is her responsibility to disclose HIV status to the child in my presence. In principle, it is not the responsibility of nurses to disclose their HIV status to the children. The people who are allowed to disclose their HIV status to children should either be caregivers or parents. (Participant 3B) Theme 2.1: Coordination of multidisciplinary team for support Five (5) sub-themes emerged from this theme. These include liaison with counselors for HIV testing, counseling, and disclosure, referral to the social worker for support, referral to the dieticians/nutritionist for nutritional support, and referral to the law enforcement officers for security support. 2.1 Sub-theme 1.2.1: Referral to psychologists The challenges faced by caregivers of HIV/AIDS orphans affect their strengths in executing caring responsibilities. The participants reported that if they come across such cases, they refer the caregivers of HIV/AIDS orphans to psychologists. One of the participants echoed the following: ‘‘All these overwhelming circumstances faced by caregivers affect their psychological well-being e.g., if you do not have food at home, and on the other hand you must give children treatment this automatically affects the psychological well-being therefore we will be forced to bring the service of psychologist for counselling.’’ (Participant 1A) The same sentiment was shared by one of the participants who said: ‘‘In the cases whereby caregivers are unable to cope, we rope in the psychologist because some of these people need intensified counselling from the specialist who can take them through the whole process of counselling. I don’t think social work and psychologist duties are the same, but I would say psychologist can intervene better in this matter.’’ (Participant 3A) The participants also refer caregivers of HIV/AIDS orphans who are not willing to disclose their HIV status to the children. The following was echoed: ‘‘To add to what my colleague has just presented, disclosure is done by caregivers or parents but if she is reluctant to disclose, they involve us. There are psychologists in clinics. They do have schedules for visiting clinics. We refer both caregiver and a child to the psychologist to empower him/her with relevant knowledge and skills on how to disclose the status to the child.’’ (Participant 2E) 2.2 Sub-theme 1.2.2 Referral to the social workers for support Referral to the social workers for support emerged as the second subtheme. Participants reported that they worked closely with social workers to refer cases where caregivers of HIV/AIDS orphans were not registered for social grants and when the grants were not utilized appropriately. One of the participants expressed herself as follows: ‘Some caregivers are misusing the grants. You will find that when we conduct home visits, children are not well taken care of, and the child has lost weight and is wearing old clothes just because the caregivers buy or use the grants to buy liquor. If we come across such cases, we involve social workers to intervene so that the grants can be given to the relevant people who are taking care of the HIV/AIDS orphan full time.’ (Participant 2C) Another participant echoed the following: ‘I think I have mentioned the social worker role where we, as nurses, cannot win the challenging situation; we seek their input and services. If some do not have grants, some don’t have birth certificates and road to health charts, and these are the documents needed to apply for grants. When all these documents are gathered, it will be easy for the social worker to recommend them for grants.’ Participant 1D One of the participants supported the sentiment as follows: ‘Usually, we compile a list for maybe three months to provide food parcels to, for example, Family A, B, and C, and in the next cycle, we give to Family D, E, and F. Social workers have profiles of all families. In this case, they will be able to know whether families that are provided with food parcels deserve that privilege.’ (Participant 3C) 2.3 Subtheme 1.2.3: Referral to the Dieticians/Nutritionist for nutritional support Referral to the Dieticians/Nutritionist for nutritional support was identified as the fourth subtheme. Participants reported that caregivers unable to buy food are referred to dieticians for food parcels. One of the participants expressed the following: ‘The dieticians came in when we assessed the families and found out they were not eating well. We then invite the dietician to come and conduct further assessment and recommend food parcels if need be. In cases where a child is not growing well, the child will be placed on a special diet for maybe a month to see if s/he cannot pick up weight. ’ (Participant 1E) Orphaned children who are malnourished are also referred for supplements. The participants echoed the following: ‘We also have a team of nutritionists and dieticians assisting us here in the sub-district. When we have a child of poor nutritional status since caregivers experience many challenges, we then involve them to intervene. They assess them first and offer some food parcels to help improve the child's weight.’ (Participant 3A) Another participant added: ‘Regarding HIV/AIDS orphans who are not thriving well, we always involve nutritionists as members of a multidisciplinary health team to intervene by putting them on the correct diet and food parcels that will improve body weight so that it can be interpreted in line with age.’ (Participant 2C) 2.4 Subtheme 1.2.4: Referral to the law enforcement officers for security support. Referral to law enforcement officers for security support emerged as a subtheme where participants reported that when they come across cases whereby HIV/AIDS orphans are being abused, they refer such cases to the police for further investigation and management. The following was echoed: ‘If the orphan is abused, it is the prerogative of the social workers to involve the South African Police Services to establish the root cause of abuse and further management.’ (Participant 2F) One of the participants stated that they also involve the police when the needs of the children are neglected and said: ‘One of the common cases is child neglect. Orphans are cared for by relatives when their parents pass away. So, if their stay with relatives is unstable, for example, they move from one family to another for two months with a cousin and two months with an uncle and aunt. It is challenging to decide who is entitled to a foster care grant. For example, the uncle took the foster care grant during the child’s stay at his home and used the funds to buy his own needs and ignored to buy clothes and other essentials for the orphan. Therefore, we involved the police and social workers to intervene.’ (Participant 3D) One of the participants emphasized the importance of law enforcement and said: ‘There are recreational places adolescents and adults like visiting. In those places, some of them are killed, some raped, and some stay there for quite some time without coming back home. All these problems require people who can do follow-up, and in this case, police officers are the most relevant agents to do that.’ (Participant 3A) Another participant reported: ‘You will find that some caregivers do not report cases of abuse of HIV/AIDS orphans. When we encounter such cases, we do a thorough assessment before involving social workers. She will have to confirm her assessment as well. After assessments, there will be a need to involve law enforcement officers .’ (Participant 3D) Theme 1.3: Facilitation of support groups for both caregivers and children orphaned by HIV/AIDS Two (2) subthemes emerged from this theme, including adherence clubs and adolescent youth-friendly services. 3.1 Sub-theme 1.3.1: Adherence clubs Adherence clubs were identified as the first subtheme in this study. The adherence clubs are reserved for all patients who are on chronic treatment. The initiative aimed to reduce overcrowding at the facilities by scheduling the exact dates for treatment collection for both parties. Adherence clubs assisted caregivers in readily disclosing their status to orphans without postponing. One of the participants indicated: ‘The Department of Health has introduced a project called Adherence Clubs. In the cases of both caregivers and the orphan taking treatment, for example, chronic treatment and ART, we schedule the same follow-up dates for both. The caregivers benefit from this project of adherence clubs because they do not struggle to disclose their HIV status to the orphans. If the HIV/AIDS orphan asks questions, the caregiver just responds shortly by saying, ‘I am also taking treatment’. Most of the time, we encourage caregivers to take their medication at the same time as the orphans. There has been huge progress regarding disclosure since this initiative was implemented.’ (Participant 3B) One of the participants elaborated more on the terms of reference of adherence clubs. They also address the needs of patients who are on other treatments. She said: ‘We have initiated adherence clubs that are yielding positive results in the villages. These adherence clubs are not only for people who are HIV positive. They are for all chronic patients. They end up seeing each other at the clubs. We pack treatment according to a patient’s needs so no one can judge another regarding their treatment. As a result, it makes things easier for us. We don’t write about the disease that one suffers from nor the treatment that individual takes. During visits to adherence clubs, we give health education on specific topics. It is effective and impacts caregivers, and they become free from stigma and discrimination.’ (Participant 1C) The club has played a fundamental role in improving adherence to treatment and the attitude of the community towards caregivers of HIV/AIDS orphans. The following was echoed: ‘The club has improved adherence to treatment because it facilitates the process of patients accepting themselves. As caregivers of orphaned children, adherence clubs have helped to reduce the stigma and discrimination. The club has made all categories of people collecting treatment to relax after noticing that they are not alone in taking chronic treatment. ’ (Participant 2F) 3.2 Subtheme 1.3.2 Adolescent Youth Friendly Services (AYFS) The AYFS emerged as the subtheme in this study. The participants indicated they started a support group for adolescents at the facilities. The support group also discusses activities such as health education and other issues affecting adolescents' health. One of the participants mentioned: ‘Yeah, the other point we did not mention is that we also have teenager clubs. We invite them, and they can come along with caregivers to the clinic. We set a date and time, and when they arrive, we carry out activities with them, including how to get treatment and the importance of adhering to treatment. The adolescents are bound to come along with caregivers, and I think the initiative is productive.’ (Participant 1D) The main aim of initiating adolescents’ clubs was to create a platform where matters that are related to HIV and affect the health of adolescents are ventilated. One of the participants echoed the following: ‘The main purpose of this teen club is to make sure that these teenagers accept their status and that they can teach those who are not HIV positive about the disease and to accept the status if the outcomes of HIV counselling and testing are positive. Again, teenagers’ understanding of the disease makes the lives of caregivers very easy because caregivers sometimes struggle to convince teenagers to accept their status; therefore, teen clubs play a major role in motivating both teenagers and caregivers. There will be a good working relationship at home, and confidentiality will not become an issue when the child is affiliated with teen clubs.’ (Participant 1C) The teenagers are also advised to attend with caregivers of HIV/AIDS orphans, and the sessions that are conducted regularly boost their confidence. One of the participants echoed the following: ‘At the AYFS, we capacitate adolescents with knowledge and skills regarding different conditions like HIV, STIs, and other chronic conditions. The sessions empower them with knowledge that guides them on how to conduct themselves when they have tested HIV positive. It also assists caregivers in disclosing their HIV status to children on time. If there is a delay in disclosure, children will start asking the caregiver many questions like ‘What is the medication that I am taking? Why am I taking the medication?’ This will embarrass the caregivers, but this will ultimately compel the caregivers to disclose their HIV status to the child.’ (Participant 3E) Discussion This study aimed to explore and describe the support provided by OTLs to the caregivers of HIV/AIDS orphans. To our knowledge, this study is a new contribution to the body of knowledge. The objective of this study was successfully met, and three (3) main themes emerged from this study, namely the conduction of home visits to the caregivers of HIV/AIDS orphans, the coordination of multidisciplinary teams for support, and the facilitation of support groups for both caregivers and HIV/AIDS orphans. This study revealed various support that is provided by OTLs to caregivers of HIV/AIDS orphans. Conducting home visits at the homes of the caregivers of HIV/AIDS orphans emerged as the primary theme, and subthemes were also identified in this study. Many of the OTLs reported that conducting home visits assisted them in identifying orphaned children not adhering well to medication. In such cases, OTLs assigned CHWs to implement directly observed therapy (DOT) on caregivers who are not giving orphaned children medication accordingly. Researchers defined DOT as a strategy that non-healthcare professionals use to observe whether the patients take treatment [42]. The findings of this study are consistent with the outcomes of the study conducted in Zimbabwe that reported that nurses involved CHWs when there were instances of ART non-adherence among HIV/AIDS orphans [43]. The authors went on to establish that during home visits, CHWs work closely with caregivers to identify any barriers that might prevent adherence to medication. Following this results from a systematic review and meta-analysis also confirmed that DOT was beneficial to people who were more non-adherent to ART [44]. The authors also suggested that when employing DOT on people who exhibit non-adherence behavior, steps should be taken to ensure adherence. These steps of ensuring adherence to ART were evident in the study conducted in Zimbabwe, CHWs visited the caregivers of HIV/AIDS orphans at home to follow up on matters that arose from scheduled clinical appointments and provide them with adherence support [45]. Existing literature and the current study categorically described the importance of the DOT strategy. Within the context of this study, the strategy improved adherence among HIV/AIDS orphans and capacitated caregivers with skills on how to maintain and sustain adherence. Each one of the OTLs was obliged to adopt one HIV/AIDS orphan from each family and employ a holistic approach to ensure that the needs of that orphan are well taken care of. In line with the literature, the study conducted in SA revealed that CHWs used a community-based intervention strategy to supervise caregivers of HIV/AIDS orphans on medication giving by visiting them weekly in their respective households [46]. Similar findings were reported in Uganda, where the Grandparents Action Support Project (GAS) was established to enhance the capacity of older caregivers to provide care to HIV/AIDS orphans and to improve the overall welfare of the families taking care of these children [47]. This study's evidence demonstrated the strategy's broad benefits, including the development of caring abilities for caregivers of HIV/AIDS orphans. The adopt-a-child approach has made it easier for OTLs, CHWs, caregivers, and HIV/AIDS orphans to have healthy relationships. Routine blood and growth monitoring played a fundamental role in assessing viral suppression among HIV/AIDS orphans. In concurrence, the cross-sectional study conducted in Tanzania reported that the households of caregivers of HIV/AIDS orphans that were monitored by Community case workers (CCWs) were more likely to be virally suppressed than those who did not [48]. The authors continued by asserting that there was a 149-fold increase in the likelihood of viral suppression in HIV/AIDS orphans who adhered to ART at a rate of >95% compared to those who did not. In this study, the OTLs visited HIV/AIDS orphans daily who did not thrive well or were malnourished. During home visits, the OTLs assess how caregivers give medication and other aspects of a healthy lifestyle. After three (3) months, OTLs take routine blood monitoring to assess if the viral load is being suppressed and if the CD4 count is going up, as both are elements of growth monitoring and medication adherence. The literature revealed that orphaned children with viral suppression always present with improvement in clinical well-being, weight gain, and reduction of opportunistic infections [49]. Researchers whose focus was on low- and middle-income countries viewed viral load monitoring as a useful tool for identifying children living with HIV who require extra adherence assistance, minimizing regimen switching, and maintaining treatment alternatives [50]. Based on the findings of this study and existing literature, we assume that optimal adherence to ART play is of paramount importance to improve CD4 count and suppress the viral load of HIV/AIDS orphans. It is evident in this study that OTLs had measures in place to support caregivers to sustain adherence. Another interesting finding revealed by this study was that the OTLs were responsible for providing caregivers of HIV/AIDS orphans with any kind of support during disclosure. In line with previous research, a qualitative study carried out in the Eastern Cape of South Africa found that healthcare workers (HCWs) used a variety of techniques to assist caregivers with disclosure [51]. These included talking with caregivers to find out what their primary disclosure challenges were and teaching them how to disclose and handle the emotional responses of children after disclosure [51]. The cross-sectional survey about health care workers (HCWs) perspectives on disclosure to HIV-infected children conducted in Gauteng and Mpumalanga Provinces of South Africa revealed different results regarding who is entitled to disclose [52]. According to the survey, 48,5% of respondents felt that caregivers should take the initiative to disclose, 42.7% believed that caregivers and HCWs should share responsibility for disclosure, and 8.8% said that HCWs should take the lead in disclosure [52]. Up to now, it is not clear about who should conduct disclosure between HCWs, and caregivers based on existing literature. Contrary to the results of the current study, a qualitative study carried out in Zimbabwe revealed that most community leaders and healthcare professionals believed that healthcare personnel were the best individuals to disclose HIV status to children who are infected [53]. Similarly, a qualitative study conducted in Zimbabwe discovered that most adolescents preferred disclosure to take place in front of HCWs in a clinical setting since they have the professional abilities to handle any potential discomfort and have access to reliable information [54]. We therefore recommend that there be standardized rules in place that specify the relevant stakeholder to disclose HIV/AIDS to children living with HIV, based on the findings of the current study and the literature that has already been published. The OTLs further used multidisciplinary teams (MDT) as a source of support to the caregivers of HIV/AIDS to address various needs that require professional intervention. The multidisciplinary team refers to a group of different disciplines working together to improve the health and well-being of individuals [55]. The Elizabeth Glazier Paediatrics AIDS Foundation (EGPAF) guidelines indicate that if healthcare workers find caregivers who are reluctant to disclose their status to HIV/AIDS orphans, they must refer them to either social worker, nurses, psychologists, and other professionals for further counselling and support [56]. Within the context of this study, OTLs referred caregivers who had difficulty disclosing their HIV status of HIV/AIDS to psychologists for counselling and support. The quantitative study conducted by Nicastro et al. provided evidence in support of this finding, revealing that psychologists employed family group psychotherapy as a means of facilitating disclosure to families of children living with HIV [57]. The quality of life and overall well-being of orphaned children were found to be enhanced by group psychotherapy, which also decreased the children's anxiety levels and boosted their resilience. Caregivers who were eligible to apply for social grants and did not have relevant documents were referred to social workers by OTLs for assistance. This finding agrees with the study conducted in SA, where social workers assisted orphans who did not have birth certificates to apply for social grants [58]. The author further reported that social workers also assisted orphans who did not have birth certificates to be admitted to schools. Consistent with previous studies, the study conducted in Zimbabwe reported that the Department of Social Welfare assisted caregivers in paying school fees and medical bills for HIV/AIDS orphans [56]. On the contrary, the qualitative study conducted in NWP, SA whereby caregivers of HIV/AIDS orphans were complaining about a lack of support from the social workers [59]. Furthermore, the authors claimed that one of the caregivers waited for the assistance of social workers to apply for a foster care grant for more than a year. Existing literature reported that the Department of Social Development in South Africa acknowledged that insufficient numbers of available social workers make it difficult to deliver social services where they are needed [60,61]. The authors further revealed that social workers simply cannot deal with hundreds of thousands of foster care placements on top of the other services they need to provide [60,62]. Based on the evidence of the current study and existing literature, we suggest that OTLs should collaborate with social workers to ensure the smooth running of the services that they render to caregivers. HIV/AIDS orphans presenting with malnutrition and failure to thrive (FTT) were referred to dieticians for nutritional support. As defined by [63]. malnutrition is when people receive insufficient or excessive amounts of specific nutrients, which can negatively impact their health and result in an inability to thrive. According to [64] malnutrition is the most common reason children do not grow as well as they should. Similarly, the literature review demonstrated that ready-to-use therapeutic meals (RUTFs) improved the way severe acute malnutrition was treated in children living with HIV/AIDS by giving them access to foods that promote fast weight gain and are safe to use at home [65,66]. In addition, a study conducted in Zimbabwe discovered that children with HIV who were given nutritional supplements by RUTFs for ten months, between the ages of twelve and thirty-six months, gained more weight of 51.2% than children who were not infected (26.0%) [67,68]. The findings of this study support existing literature that children living with HIV who were malnourished and placed on nutritional supplements were showing huge progress. In this study, dieticians administered nutritional supplements for a certain period to bolster the weight of the orphans who were malnourished, and food parcels were provided for the entire family. This study described the support that should be given to caregivers if they discover instances of abuse and neglect involving HIV/AIDS orphans. The concepts "abuse" and "neglect" describe a scenario where a parent or caregiver causes physical, sexual, or psychological harm to children [69]. Suppose OTLs discover that an HIV/AIDS orphan has experienced abuse or neglect of any kind, whether it be psychological, emotional, physical, or sexual; in such cases, they should consult social workers to conduct an assessment and refer the case to law enforcement officers. Social workers’ responsibilities include conducting thorough assessments, offering initial counselling, drawing an intervention plan, and making therapy referrals [70]. In the study conducted in KwaZulu Natal province of South Africa social workers were not involved in the incident that involved an orphan who was sexually abused [71]. Despite the efforts made by the orphan child to report the incident to the caregiver, the sexual abuse incident continued. The orphan child decided to escalate the incident directly to the teacher at school who assisted her in reporting that to the law enforcement department. Consequently, the arrest of the perpetrator was affected by law enforcement officers however, this incident did not sit well with the caregiver who assaulted the orphan child for reporting the incident to the law enforcement officers [71]. The data reported here appear to support the assumption that orphaned children are sometimes not saved because caregivers who are supposed to offer them full protection are involved in the same acts of abuse against the orphaned children. A reasonable approach to tackle this issue could be to actively involve social workers as they are trained to handle such incidents. The effectiveness of the involvement of social workers in incidents of abuse of children has been exemplified in a study conducted in the Western Cape province of South Africa [66]. Children who were abused by the primary caregivers were removed from their care and placed in child and youth care centers (CYCC) [72]. Alternatively, the involvement of the social workers by OTLs could also aid in identifying people from the family who can foster the orphaned children who are found to be abused by the caregivers as reported by the current study. This action can assist in ensuring that the physical, psychological, and emotional well-being of the orphaned children are safeguarded. Another interesting finding reported by this study was the use of adherence clubs and adolescent youth-friendly services by OTLs to improve the relationship between caregivers and HIV/AIDS orphans. This study highlighted that the Department of Health (DoH) established adherence clubs (ACs) throughout SA. Adherence clubs support cross-government initiatives to improve population health and well-being. The purpose of ACs is to accommodate the increasing number of stable patients undergoing treatment, guarantee the quality of care, and lessen the workload on healthcare personnel in the facilities [73]. The ACs are not explicitly used for HIV/AIDS but for other chronic conditions as well. Consistent with existing literature, a study conducted in Mpumalanga on community-based adherence clubs indicated they played a crucial role in reducing overcrowding in healthcare facilities, defaulter rates, improving treatment adherence, and reducing stigma and discrimination [74]. These results are similar to those reported in the study conducted in Haiti whereby the Kids Club program assisted caregivers and children living with HIV with psychosocial development and well-being through group interaction [75]. It has been reported that the Kids Club program was crucial in giving orphaned children the educational opportunities they needed to overcome their shyness, boost their self-esteem, give them encouragement and hope, and bring pleasure into their lives. Individuals who disclosed to the club that they were HIV-positive discussed how being a part of it had improved their knowledge of the virus, their ability to maintain their health, and their outlook on life [75]. Moreover, caregivers also reported how treatment treatment-taking behavior of orphaned children who attended the Kids Club improved. Similar results were reported in a recent study that the ACs smoothened the relationship between caregivers and HIV/AIDS orphans. The OTLs further used adolescent youth-friendly services (AYFS) to educate orphaned adolescents about topics that affect their health and well-being. The findings of this study are aligned with previous studies that reported that peer support groups for adolescents and family clubs assisted adolescents in disclosing their status to significant others [76]. The author further reported that the initiative provided the caregivers of HIV/AIDS orphans with the opportunity to acquire more knowledge and skills on how to care for adolescents living with HIV, treatment adherence, and coping with stigma and discrimination. Similarly, a qualitative study conducted in five primary healthcare facilities in the SA revealed the effectiveness of a psychosocial support intervention (PSS) for adolescents on ART [77]. This initiative was implemented in an adolescent-friendly and safe space in the clinics in the form of social clubs. Interestingly, the authors stated that the PSS intervention promoted treatment adherence through peer support, health education, and relationships between adolescents, caregivers, and healthcare providers [77]. Another significant finding reported by the same authors was that the PSS intervention expedited full disclosure of HIV status to adolescents was also expedited by PSS intervention. Taken together, this finding supports the current study by highlighting the significance of support groups in reducing stigma and discrimination against caregivers and orphaned adolescents. Both studies further revealed the importance of support groups by harnessing the caring environment of the caregivers. In support of this finding, a qualitative study conducted in NWP of SA revealed that social clubs play a significant role in creating a supportive caring environment for caregivers of HIV/AIDS orphans by improving their psychological and emotional well-being [78]. To date, the success of AYFS has enhanced caregivers with multiple skills in how to care for HIV/AIDS orphans. 5. Limitations Recruitment of OTLs was challenging because the WBPHCOT program is championed by retired nurses due to the shortage of nurses in the NWP of SA. During data collection for this study, their contracts were expired therefore it was not easy to get hold of the OTLs. Conclusions The researchers struggled with the recruitment of the OTLs because the PHC re-engineering program is championed by retired nurses whose contracts with the DoH had expired. Declarations Author Contributions: BJM formulated the title, BJM, was responsible for the methodology and BJM was responsible for data collection, BJM, SM, MD, and MM analyzed data, BJM wrote the draft, SM, MD, and MM reviewed and edited the manuscript. Funding: This study was funded by the Health and Welfare Sector Education and Training Authority (HWSETA) however, North West University (NWU0 will be responsible for the publication fee. Institutional Review Board Statement: The study was conducted by the Declaration of Helenski and approval to conduct the was granted by the North West University Health Research Ethics Committee (NWU-00196-21-A1. Before conducting the study, permission was obtained from the North West Province Department of Health. Informed Consent Statement: All processes to obtain informed consent were adhered to, and the participants were told about their right to voluntarily participate and withdraw at any time when the need arose. The study was approved by North-West University (NWU) Health Science Research Ethics (NWU-00196-21-S1). Data Availability Statement: Data collected in this study is not available to the public. Only the researcher and study leaders have access to it. Moreover, the data are not publicly available due to privacy regulations. Currently, it is kept on a password-controlled computer to maintain confidentiality. 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J Int AIDS Soc. 2019;22(3):e25235. Tshuma N, Mosikare O, Yun JA, Alaba OA, Maheedhariah MS, Muloongo K, Nyasulu PS. Acceptability of community-based adherence clubs among health facility staff in South Africa: a qualitative study. Patient preference and adherence. 2017 Sep 11:1523–31. Settergren SK, Philippe R, St. Louis J, Segaren N, Boisson S, Lewis T, Désinor O, François K. Importance of support groups to the health and well-being of vulnerable children and young people living with HIV: a case study of the Kids Clubs program in Haiti. BMC Health Serv Res. 2021;21:1–2. Rencken CA, Harrison AD, Mtukushe B, Bergam S, Pather A, Sher R, Davidson BJ, Carrihill M, Matiwane M, Kuo C, Galárraga O. Those people motivate and inspire me to take my treatment. Peer Support for Adolescents Living With HIV in Cape Town, South Africa. J Int Association Providers AIDS Care. 2021;20:1–9. Okonji EF, Wyk BV, Hughes GD, Mukumbang FC. Implementation of a Psychosocial Support Intervention for Adolescents on Antiretroviral Treatment: Challenges and Experiences from Ehlanzeni District, South Africa. J Int Association Providers AIDS Care (JIAPAC). 2022;21:23259582221121094. Molato BJ, Moloko-Phiri SS, Koen MP, Matsipane MJ. Coping mechanisms used by caregivers of HIV/AIDS orphans in North West Province, South Africa, 2024b [Unpublished]. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 31 Aug, 2024 Read the published version in BMC Nursing → Version 1 posted Editorial decision: Revision requested 17 Jun, 2024 Reviews received at journal 12 Jun, 2024 Reviewers agreed at journal 02 Jun, 2024 Reviews received at journal 13 May, 2024 Reviewers agreed at journal 06 May, 2024 Reviewers agreed at journal 02 May, 2024 Reviewers invited by journal 02 May, 2024 Editor assigned by journal 02 May, 2024 Submission checks completed at journal 02 May, 2024 First submitted to journal 20 Apr, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4296065","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":299857324,"identity":"2d9e1b31-b355-41ca-9d7e-5e61629f9338","order_by":0,"name":"Boitumelo J. Molato","email":"data:image/png;base64,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","orcid":"","institution":"North-West University","correspondingAuthor":true,"prefix":"","firstName":"Boitumelo","middleName":"J.","lastName":"Molato","suffix":""},{"id":299857325,"identity":"7c2c6c23-4b95-4038-95fb-2fe803807aac","order_by":1,"name":"Salaminah S. Moloko-Phiri","email":"","orcid":"","institution":"North-West University","correspondingAuthor":false,"prefix":"","firstName":"Salaminah","middleName":"S.","lastName":"Moloko-Phiri","suffix":""},{"id":299857326,"identity":"530c6508-6ea7-4ab4-8a54-0841963482f4","order_by":2,"name":"Magdalena P. Koen","email":"","orcid":"","institution":"North-West University","correspondingAuthor":false,"prefix":"","firstName":"Magdalena","middleName":"P.","lastName":"Koen","suffix":""},{"id":299857327,"identity":"812525b2-4826-4389-ae39-85d14ac908ae","order_by":3,"name":"Molekodi J. Matsipane","email":"","orcid":"","institution":"North-West University","correspondingAuthor":false,"prefix":"","firstName":"Molekodi","middleName":"J.","lastName":"Matsipane","suffix":""}],"badges":[],"createdAt":"2024-04-20 06:13:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4296065/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4296065/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12912-024-02282-4","type":"published","date":"2024-08-31T15:57:06+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":63821237,"identity":"973da0fc-fda8-45be-a596-eddbff27aaa3","added_by":"auto","created_at":"2024-09-02 16:12:46","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":470227,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4296065/v1/aa63b627-cf4d-49dc-acda-07d268cd8daa.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Support provided by outreach team leaders to caregivers of HIV/AIDS orphans in the North-West Province of South Africa","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMany children are left as orphans without help or resources after their parents pass away from Human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] This incident has put them at risk for hunger, psychological distress, and impoverishment [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. After the death of the parents, orphaned children are usually cared for by primary caregivers [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Previous studies revealed that caregivers of HIV/AIDS orphans face challenges that include a lack of support from social services and family, stigma, and discrimination when caring for HIV/AIDS orphans [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Due to the high rate of unemployment, caregivers are unable to provide orphaned children with basic needs such as access to necessities like food and clothing [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. To help caregivers with some of the financial challenges involved in raising orphans, the South African government offers social security in the form of Foster Care or Child Support. Notwithstanding the restricted financial resources, poverty continues to be a significant issue that impacts orphaned children both before and after a parent passes away [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. With regards to the older caregivers, caregiving is not easy due to age they face many difficulties that include the execution of duties without undergoing proper training for caregiving. The authors further claimed that the challenges that older caregivers face predispose them to burdens that affect their physical, and psychological well-being [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Furthermore, grandparent caregivers often present with health challenges, such as poorer emotional well-being and declining psychological health, because of stressors arising from caring for their grandchildren [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Consequently, the stress of providing care exposes caregivers to long-term illnesses that make it difficult for them to perform their daily caregiving responsibilities [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Given these challenges, the South African (S.A.) government introduced primary health care (PHC) re-engineering strategy to promote health by providing services to society at their respective homes [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe PHC re-engineering model comprises ward-based primary health care outreach teams (WBPHCOT), district specialist teams, and school health teams [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The author further indicates that this strategy represents an attempt to formalize, standardize, and integrate community-based services into the PHC system. The WBPHCOTs act as a link between healthcare facilities and the communities they serve [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. This can be particularly helpful in rural places where people must travel great distances for medical care and when communities are underserved and disadvantaged. The purpose of PHC re-engineering is to establish a district health system focused on solving society's most pressing health needs through PHC teams [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Each ward has a WBPHCOT led by a professional nurse commonly known as an outreach team leader (OTL).\u003c/p\u003e \u003cp\u003eIn the South African setting, the OTLs are considered community health nurses because they provide health education, encourage behavioural changes that empower people to take charge of their health, and promote health within the community [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. The activities performed by OTLs include household and individual assessments, identification of problems, provision of interventions, and referrals [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. These routine visits enable OTLs to conduct different assessments of the individuals they visit. The OTLs conduct assessments on caregivers of HIV/AIDS orphans; they intervene and provide the needed support. Existing literature has highlighted the support provided by community health workers (CHWs) as members of WBPHCOTs who work closely with OTLs [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. In the United States, CHWs play an essential role in the treatment of diseases like hypertension, diabetes, HIV, cancer screening, and lowering the risk of cardiovascular disease [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. In South Africa, CHWs provide the support that contributes to the successful implementation of the human immunodeficiency virus (HIV) program [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Up to now, the support provided by OTLs in the North West Province (NWP) of South Africa (SA) remains unknown regardless of the challenges faced as reported by existing literature [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Therefore, the researchers found it necessary to explore and describe the support provided by outreach team leaders in the North West province of South Africa. This study addresses the third objective of the main (PhD) study which aims to develop health promotion strategies to improve the health and well-being of caregivers of HIV/AIDS orphans in NWP of SA. Exploration of the support provided by OTLs may assist in formulating recommendations that focus on mitigating circumstances surrounding caregivers of HIV/AIDS orphans. Furthermore, the findings of this study might assist in developing health promotion strategies as the main objective of the study.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003e2.1 Aim\u003c/p\u003e\n\u003cp\u003eThis study aimed to explore and describe support provided by WBPHCOT leaders to the caregivers of HIV/AIDS orphans in the NWP of SA.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e2.2 Research design\u003c/p\u003e\n\u003cp\u003eThis study used the qualitative exploratory, descriptive design to explore and describe the support provided by OTLs to the caregivers of HIV/AIDS orphans in the NWP of SA. Through qualitative research, researchers were able to get insight into the meaning that people attribute to their experiences by getting access to research participants\u0026apos; thoughts and feelings [30]. Exploratory research design was used to better understand the nature of the problem because little was known regarding the phenomenon [31,32]. Descriptive research aims to shed light on current issues or problems through a data collection process that allows them to be fully descriptive and go into detail about the phenomena \u0026nbsp;[33]. Moreover, the descriptive research design was used to capture the most authentic and accurate description of data collected to describe the support provided by OTLs to the caregivers of HIV/AIDS orphans in Ngaka Modiri Molema district in the NWP of SA. concerning contextual research design, we interacted with the caregivers in the village in which they reside \u0026nbsp;[34]. Furthermore, the environment where data was collected was free from manipulation natural surroundings entails that the environment is free from manipulation \u0026nbsp;[35].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e2.3 Study Setting\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe study was conducted in five local municipalities of the Ngaka Modiri Molema District of the NWP of SA. The local municipalities where the study was conducted were Mahikeng, Ratlou, Ramotshere Moiloa, Ditsobotla, and Tswaing. The district shares an international border with Botswana and is located at the center of the province.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e2.4 Population and Sampling\u003c/p\u003e\n\u003cp\u003eThe population of the study was OTLs rendering care to the caregivers of HIV/AIDS orphans in Ngaka Modiri Molema District. The OTLs considered eligible for this study were registered nurses with a qualification in\u0026nbsp;community nursing, with or without additional qualification of PHC, and had the experience of at least six months as OTLs. Non-probability purposive sampling was used to sample the OTLs who were eligible to actively participate in the study. Every participant in the target population does not have equal chances because the sample population was chosen in a non-systematic manner \u0026nbsp;[36].\u0026nbsp;Purposive sampling assisted in selecting participants who shared fundamental information related to the study [37].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e2.5 Data collection\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eData was collected face-to-face at the local clinics in the Ngaka Modiri Molema district of the NWP. Five (5) focus group sessions were conducted to achieve the objectives of the study. The study used semi-structured focus group discussions to gather information from the OTLs. The interview guide was developed to achieve the objectives of the study.\u0026nbsp;The exploratory question was: What support is provided by OTLs to caregivers of children orphaned by HIV/AIDS in NWP, SA?\u0026nbsp;An audio recorder was used to record the discussions. The discussions lasted for 45-60 minutes. To accomplish the goals of the study, open-ended and brief questions were asked \u0026nbsp;[38]. Field notes were used to capture all activities that unfolded during the discussions to ensure accurate recording of vital information [39]. Interviews were conducted in English and data saturation was reached in focus group number five. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e2.6 Data analysis\u003c/p\u003e\n\u003cp\u003eThe researcher and independent co-coder used six (6) steps of thematic analysis to analyze data as stipulated by \u0026nbsp;[40]. In terms of familiarisation of data, which is the first step, we have read and re-read the transcripts to familiarize ourselves with the data. The second step of thematic analysis followed was the generation of initial codes [39, 40]. The data was arranged in a methodical and comprehensible manner. After that, we each started coding a transcript on our own. Every text passage that appeared to be pertinent to or directly addressed our study issue was coded as we went through each transcript. After we were done, we reviewed, compared, and adjusted our codes before going on to the remaining transcripts. The data was arranged in a methodical and comprehensible manner. After that, we each started coding a transcript on our own [39, 40]. The quotations that emerged from the interviews were used to cite the findings.\u003c/p\u003e\n\u003cp\u003eEvery text passage that appeared to be pertinent to or directly addressed our study issue was coded as we went through each transcript. After we were done, we reviewed, compared, and adjusted our codes before going on to the remaining transcripts [39, 40]. In the third step which is search for themes, when we looked at the codes, it was evident that some of them fit into a theme. The codes were arranged into more general themes after this process, which appeared to address a particular aspect of the research question \u0026nbsp;[39, 40]. Concerning the fourth step which is reviewing themes, this stage involves going over, revising, and expanding on the initial topics that we determined in Step 3 to check coherence. All information related to each theme was compiled.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAfter reading the information related to each theme, we evaluated if the information supported the theme. In terms of the fifth step which was to define themes, we determined the fundamental idea of the theme as well as its main points. This was followed by evaluating each sub-theme in terms of its relevance to the main theme and its interactions with other sub-themes [39, 40]. Writing up was the sixth and the last step, before writing the report, the researcher and co-coder met to check if they had similar themes and sub-themes of the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e2.7 Trustworthiness\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTrustworthiness\u003c/p\u003e\n\u003cp\u003eThe researcher ensured trustworthiness by adhering to the four principles of trustworthiness namely, credibility, transferability, confirmability, and dependability [41].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCredibility\u003c/p\u003e\n\u003cp\u003eThe researchers interacted with the participants for a long time to know their viewpoints.\u0026nbsp;Reflexivity was upheld throughout the data collection, analysis, and interpretation stages to reduce bias in the findings. Numerous methods of gathering data were employed to verify information from multiple perspectives, strengthening the veracity of the descriptions [41].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTransferability\u003c/p\u003e\n\u003cp\u003eA thick description was maintained by fully outlining the research setting, participants, and techniques. To ascertain whether the results would be relevant or transferable to comparable populations or circumstances outside the study context, the sampling techniques that were employed were explained, along with the reasons for participant selection [41].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConfirmability\u003c/p\u003e\n\u003cp\u003eThe study\u0026apos;s research methods and decision-making processes were recorded. Transparency and traceability were made easier by keeping track of all decisions made throughout the study, including adjustments to methods or analysis [41].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConfirmability\u003c/p\u003e\n\u003cp\u003eThe participants were checked to review and confirm the correctness of data to improve confirmability. Biasedness was reduced by discussing interpretations and findings with co-workers or experts [41].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e2.7 Ethical considerations\u003c/p\u003e\n\u003cp\u003eThis study was approved by Quality in Nursing and Midwifery (NuMIQ), a research focus in the Faculty of Health Sciences at the North West University (NWU). \u0026nbsp;Ethical clearance was obtained from the NWU Health Research Ethics Committee (NWU-00196-21-A1). The North West Department of Health gave permission to conduct the study. Before conducting the study, participants were given a full explanation regarding the purpose of the study and how the entire process would unfold. The principle of privacy was maintained by placing \u0026lsquo;\u0026lsquo;Do not disturb session in progress\u0026rsquo;\u0026rsquo; at the door, and participants\u0026rsquo; names were used. The collected data was shared only with the research team.\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 37 professional nurses from five local municipalities voluntarily participated in this study. Both genders were represented although the majority of the participants were females see Table 1 for more details. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 1: Demographic information of outreach team leaders\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.4225621414914%\" valign=\"top\"\u003e\n \u003cp\u003eVariable\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.766730401529637%\" valign=\"top\"\u003e\n \u003cp\u003eCategory\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.810707456978967%\" valign=\"top\"\u003e\n \u003cp\u003eNumber\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.4225621414914%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eGender\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.766730401529637%\" valign=\"top\"\u003e\n \u003cp\u003eMale\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.810707456978967%\" valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"51.798561151079134%\" valign=\"top\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"48.201438848920866%\" valign=\"top\"\u003e\n \u003cp\u003e33\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.4225621414914%\" rowspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003eAge in years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.766730401529637%\" valign=\"top\"\u003e\n \u003cp\u003e30-39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.810707456978967%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"51.798561151079134%\" valign=\"top\"\u003e\n \u003cp\u003e40-49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"48.201438848920866%\" valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"51.798561151079134%\" valign=\"top\"\u003e\n \u003cp\u003e50-59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"48.201438848920866%\" valign=\"top\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"51.798561151079134%\" valign=\"top\"\u003e\n \u003cp\u003e60-69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"48.201438848920866%\" valign=\"top\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"51.798561151079134%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"48.201438848920866%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.4225621414914%\" valign=\"top\"\u003e\n \u003cp\u003eNurses participating in the study per local municipality\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.766730401529637%\" valign=\"top\"\u003e\n \u003cp\u003eA\u003c/p\u003e\n \u003cp\u003eB\u003c/p\u003e\n \u003cp\u003eC\u003c/p\u003e\n \u003cp\u003eD\u003c/p\u003e\n \u003cp\u003eE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.810707456978967%\" valign=\"top\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.4225621414914%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.766730401529637%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.810707456978967%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e37\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA total of five semi-structured focus group discussions consisting of five to seven participants were conducted face-to-face see Table 2 for more details regarding the findings of the study. Three main and eleven (10) subthemes were identified in the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 2: Findings of the study\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"47.43875278396437%\" valign=\"top\"\u003e\n \u003cp\u003eMain themes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"52.56124721603563%\" valign=\"top\"\u003e\n \u003cp\u003eSub-themes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"47.43875278396437%\" valign=\"top\"\u003e\n \u003col start=\"1\" type=\"1\"\u003e\n \u003cli\u003eConduction of home visits to the caregivers of HIV/AIDS orphans.\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003ctd width=\"52.56124721603563%\" valign=\"top\"\u003e\n \u003col\u003e\n \u003cli\u003ePromotion of medication adherence among children orphaned by HIV/AIDS.\u003c/li\u003e\n \u003cli\u003eAdoption of a Child Strategy.\u003c/li\u003e\n \u003cli\u003ePerformance of routine blood and growth monitoring of children orphaned by HIV/AIDS.\u003c/li\u003e\n \u003cli\u003eProvision of physical support to the caregivers of children orphaned by HIV/AIDS during disclosure.\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"47.43875278396437%\" valign=\"top\"\u003e\n \u003col start=\"2\" type=\"1\"\u003e\n \u003cli\u003eCoordination of multidisciplinary team support.\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003ctd width=\"52.56124721603563%\" valign=\"top\"\u003e\n \u003col\u003e\n \u003cli\u003eReferral to psychologists\u003c/li\u003e\n \u003cli\u003eReferral to social workers\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eReferral to the Dieticians/Nutritionist for nutritional support.\u003c/li\u003e\n \u003cli\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Referral to the law enforcement officers for security support.\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"47.43875278396437%\" valign=\"top\"\u003e\n \u003col start=\"3\" type=\"1\"\u003e\n \u003cli\u003eFacilitation of support groups for both caregivers and children orphaned by HIV/AIDS.\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003ctd width=\"52.56124721603563%\" valign=\"top\"\u003e\n \u003col\u003e\n \u003cli\u003eAdherence clubs.\u003c/li\u003e\n \u003cli\u003eProvision of adolescent-friendly services.\u003c/li\u003e\n \u003c/ol\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThree (3) main themes and ten (10) subthemes were identified in the study. To the researchers\u0026apos; knowledge, this study appeared to be a new contribution to the body of knowledge. The WBPHCOT leaders highlighted different types of support that they provide to caregivers of HIV/AIDS orphans. The support provided by outreach team leaders included conducting home visits to the caregivers of HIV/AIDS orphans, coordinating multidisciplinary teams for support, and facilitating support groups for both caregivers and HIV/AIDS orphans. Each support provided by outreach team leaders was broken into subthemes and is discussed below.\u003c/p\u003e\n\u003cp\u003eTheme 1.1: Conduct home visits at homes of the caregivers of HIV/AIDS orphans\u003c/p\u003e\n\u003cp\u003eThe first theme identified was conducting home visits at the homes of caregivers of HIV/AIDS orphans. Four (4) sub-themes emerged from this theme, namely,\u0026nbsp;promotion of medication adherence among HIV/AIDS orphans, adoption of a child strategy, performance of routine blood and growth monitoring of HIV/AIDS orphans, and\u0026nbsp;provision of physical support to the caregivers of HIV/AIDS orphans.\u003c/p\u003e\n\u003cp\u003e1.1 Sub-theme 1.1: \u0026nbsp;Promotion of medication adherence among HIV/AIDS orphans\u003c/p\u003e\n\u003cp\u003eThe promotion of medication adherence emerged as the first sub-theme. Participants used viral load suppression as a tool to determine whether caregivers give HIV/AIDS orphans medication accordingly. For example, if they encounter such cases, they visit them at their homes to conduct assessments to exclude the underlying causes of the viral load. During home visits, the outreach team leaders conduct their assessment to confirm if the caregiver gives the HIV/AIDS orphan medication accordingly. This was expressed as follows:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eIf there is no viral suppression, it is important to check the root cause of why the child\u0026apos;s viral load is not giving in to suppression. This case does not require anything special; what we need to do as outreach team leaders is to visit them at home regularly to intensify health education on adherence to ARVs. During the home visit, you check if she is taking treatment on time and swallowing the pills; those critical points will guide you.\u0026nbsp;\u003c/em\u003e(Participant 3B)\u003c/p\u003e\n\u003cp\u003eOne of the participants reported that they used health education as a weapon to prevent viral suppression and said:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eWe always put more emphasis on health education to avoid reaching the point of poor viral suppression. If there is no viral suppression, we allocate CHWs to start them on the DOT strategy.\u0026nbsp;\u003c/em\u003e(Participant 3A)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCommunity health workers (CHWs) are involved in the cases of medication non-adherence to initiate the Directly Observed Therapy (DOT) strategy. The following was echoed.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;If there is no improvement in medication adherence, we request the CHWs to take over from caregivers by implementing the DOT strategy. The CHWs will be expected to visit the caregivers\u0026rsquo; homes every time to ensure that the child takes treatment as s/he should. This strategy helped us a lot to improve adherence among orphaned children. Also this strategy equipped caregivers with more skills because the CHWs involved them during the DOT process.\u0026rsquo;\u0026nbsp;\u003c/em\u003e(Participant 1D)\u003c/p\u003e\n\u003cp\u003e1.2 Sub-theme 1.1.2: Adopt a child strategy.\u003c/p\u003e\n\u003cp\u003eAdopt a child strategy was identified as a second subtheme in which outreach team leaders CHWs allowed participants to adopt one HIV/AIDS orphan to monitor whether the caregiver gave the child medication accordingly and to ensure that other aspects of caring were adhered to. The participants expressed the following:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;There is another strategy introduced by District Health called the Adopt-a-child strategy. About this strategy, the outreach team leaders and CHWs are expected to adopt a child each. We follow them up at home, and this strategy motivates the caregivers to better take care of the HIV/AIDS orphans. When we visit them, we check if the caregiver gives the orphan the correct medication, dose, time, and route.\u0026rsquo;\u0026nbsp;\u003c/em\u003e(Participant 1C)\u003c/p\u003e\n\u003cp\u003eAnother participant added,\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThe adopt-a-child strategy is part of physical support because we assess if the child is growing well, gaining weight, and improving on physical appearance. Adherence has improved; \u0026hellip;before the implementation of the Adopt a Child strategy, caregivers did not know how to give medication, and they did not report to us. Currently, caregivers are doing the right thing, and we are following up regularly to ensure they don\u0026rsquo;t deviate.\u0026rsquo; \u0026nbsp;\u003c/em\u003e(Participant 2B)\u003c/p\u003e\n\u003cp\u003eAnother participant outlined the significance of the strategy. She said:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;In general, this adopt-a-child strategy capacitates the caregivers of HIV/AIDS orphans with skills because after we adopt a child, we start taking care of them; we even do follow-ups at their respective places to see if they are well and getting treatment correctly. After some time, we handed the child over to CHWs for follow-ups at home to see if the caregivers were doing precisely what we did. The feedback we receive from CHWs is positive that caregivers are doing well in giving medication, there is a positive relationship between orphans and caregivers, and caregiving skills are enhanced.\u0026rsquo; \u0026nbsp;(Participant 3E)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e1.3 Sub-theme 1.1.3: Performance of routine blood and growth monitoring of HIV/AIDS orphans\u003c/p\u003e\n\u003cp\u003eMonitoring of growth and routine blood checks was identified as a third sub-theme. The outreach team leaders are expected to perform routine blood tests at the respective homes of the caregivers of HIV/AIDS orphans. The following was expressed by one of the participants:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;After adopting a child, the CHWs will be expected to borrow a weighing scale at the nearest clinic to weigh the child at home. As outreach team leaders, we take routine blood checks at home and attach the child to mentors who are CHWs to ensure that the child regularly gets food and do pill counts to measure adherence.\u0026rsquo; \u0026nbsp;\u003c/em\u003e(Participant 3C)\u003c/p\u003e\n\u003cp\u003eAnother participant expressed the following:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;If the child does not show any progress, we visit the family every day for at least three months to identify the root cause of the problem. After that, we take routine blood checks to see if there is viral suppression.\u0026rsquo; \u0026nbsp;\u003c/em\u003e(Participant 1A)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAnother participant added:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;We are closely working with CHWs. They have been capacitated with knowledge and skills related to caring. If we come across underweight children during our home visits, we refer them to CHWs to analyze their immunization cards to see whether the child is not malnourished.\u0026rsquo;\u0026nbsp;\u003c/em\u003e(Participant 2D)\u003c/p\u003e\n\u003cp\u003e1.4 Sub-theme 1.1.4 Provision of support to caregivers of HIV/AIDS orphans during disclosure\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSupporting caregivers of HIV/AIDS orphans during disclosure was identified as the fourth subtheme. The participants reported that it was the responsibility of the caregivers to disclose their status to HIV/AIDS orphans. As participants, they avail themselves of support when caregivers disclose their status to HIV/AIDS orphans. The following was verbalized:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;Nurses do not disclose HIV status, and caregivers are the ones who should do that. As nurses, we avail ourselves just for support. The orphan was already a teenager because she was 15 years old. Luckily, we managed to engage the grandmother because our concern was that the orphan was not receiving treatment. We advised the grandmother to disclose her status to her and to motivate her to start treatment by taking her chronic treatment in her presence so that the child can see that she is not the only one taking treatment alone.\u0026rsquo;\u0026nbsp;\u003c/em\u003e (Participant 2B)\u003c/p\u003e\n\u003cp\u003eAnother participant shared the sentiment of providing support during disclosure. She said:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;We avail ourselves for support when they disclose HIV status to the orphans. The orphans should not hear about it from people in the village they are not related to. If the child can hear about that from other people, the matter will not sit well with them, and that will cause them to be angry at the person who was supposed to have disclosed the status.\u003c/em\u003e\u0026rsquo; (Participant 1B)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAnother participant verbalized:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eIf I educate the caregivers of HIV/AIDS orphans about the disease of the child, it is her responsibility to disclose HIV status to the child in my presence. In principle, it is not the responsibility of nurses to disclose their HIV status to the children. The people who are allowed to disclose their HIV status to children should either be caregivers or parents.\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u0026nbsp;\u003c/em\u003e(Participant 3B)\u003c/p\u003e\n\u003cp\u003eTheme 2.1:\u0026nbsp;Coordination of multidisciplinary team for support\u003c/p\u003e\n\u003cp\u003eFive (5) sub-themes emerged from this theme. These include liaison with counselors for HIV testing, counseling, and disclosure, referral to the social worker for support, referral to the dieticians/nutritionist for nutritional support, and referral to the law enforcement officers for security support.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e2.1 Sub-theme 1.2.1: Referral to psychologists\u003c/p\u003e\n\u003cp\u003eThe challenges faced by caregivers of HIV/AIDS orphans affect their strengths in executing caring responsibilities. The participants reported that if they come across such cases, they refer the caregivers of HIV/AIDS orphans to psychologists. One of the participants echoed the following:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;\u0026lsquo;All these overwhelming circumstances faced by caregivers affect their psychological well-being e.g., if you do not have food at home, and on the other hand you must give children treatment this automatically affects the psychological well-being therefore we will be forced to bring the service of psychologist for counselling.\u0026rsquo;\u0026rsquo; \u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/em\u003e(Participant 1A)\u003c/p\u003e\n\u003cp\u003eThe same sentiment was shared by one of the participants who said:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;\u0026lsquo;In the cases whereby caregivers are unable to cope, we rope in the psychologist because some of these people need intensified counselling from the specialist who can take them through the whole process of counselling. I don\u0026rsquo;t think social work and psychologist duties are the same, but I would say psychologist can intervene better in this matter.\u0026rsquo;\u0026rsquo;\u0026nbsp;\u003c/em\u003e(Participant 3A)\u003c/p\u003e\n\u003cp\u003eThe participants also refer caregivers of HIV/AIDS orphans who are not willing to disclose their HIV status to the children. The following was echoed:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;\u0026lsquo;To add to what my colleague has just presented, disclosure is done by caregivers or parents but if she is reluctant to disclose, they involve us. There are psychologists in clinics. They do have schedules for visiting clinics. We refer both caregiver and a child to the psychologist to empower him/her with relevant knowledge and skills on how to disclose the status to the child.\u0026rsquo;\u0026rsquo; \u0026nbsp;\u003c/em\u003e(Participant 2E)\u003c/p\u003e\n\u003cp\u003e2.2 Sub-theme 1.2.2 Referral to the social workers for support\u003c/p\u003e\n\u003cp\u003eReferral to the social workers for support emerged as the second subtheme. Participants reported that they worked closely with social workers to refer cases where caregivers of HIV/AIDS orphans were not registered for social grants and when the grants were not utilized appropriately. One of the participants expressed herself as follows:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;Some caregivers are misusing the grants. You will find that when we conduct home visits, children are not well taken care of, and the child has lost weight and is wearing old clothes just because the caregivers buy or use the grants to buy liquor. If we come across such cases, we involve social workers to intervene so that the grants can be given to the relevant people who are taking care of the HIV/AIDS orphan full time.\u0026rsquo;\u0026nbsp;\u003c/em\u003e(Participant 2C)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAnother participant echoed the following:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;I think I have mentioned the social worker role where we, as nurses, cannot win the challenging situation; we seek their input and services. If some do not have grants, some don\u0026rsquo;t have birth certificates and road to health charts, and these are the documents needed to apply for grants. When all these documents are gathered, it will be easy for the social worker to recommend them for grants.\u0026rsquo; Participant 1D\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eOne of the participants supported the sentiment as follows:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;Usually, we compile a list for maybe three months to provide food parcels to, for example, Family A, B, and C, and in the next cycle, we give to Family D, E, and F. Social workers have profiles of all families. In this case, they will be able to know whether families that are provided with food parcels deserve that privilege.\u0026rsquo;\u0026nbsp;\u003c/em\u003e(Participant 3C)\u003c/p\u003e\n\u003cp\u003e2.3 Subtheme 1.2.3: Referral to the Dieticians/Nutritionist for nutritional support\u003c/p\u003e\n\u003cp\u003eReferral to the Dieticians/Nutritionist for nutritional support was identified as the fourth subtheme. Participants reported that caregivers unable to buy food are referred to dieticians for food parcels. One of the participants expressed the following:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;The dieticians came in when we assessed the families and found out they were not eating well. We then invite the dietician to come and conduct further assessment and recommend food parcels if need be. In cases where a child is not growing well, the child will be placed on a special diet for maybe a month to see if s/he cannot pick up weight.\u003c/em\u003e\u0026rsquo; (Participant 1E)\u003c/p\u003e\n\u003cp\u003eOrphaned children who are malnourished are also referred for supplements. The participants echoed the following:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;We also have a team of nutritionists and dieticians assisting us here in the sub-district. When we have a child of poor nutritional status since caregivers experience many challenges, we then involve them to intervene. They assess them first and offer some food parcels to help improve the child\u0026apos;s weight.\u0026rsquo; \u0026nbsp;\u003c/em\u003e(Participant 3A)\u003c/p\u003e\n\u003cp\u003eAnother participant added:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;Regarding HIV/AIDS orphans who are not thriving well, we always involve nutritionists as members of a multidisciplinary health team to intervene by putting them on the correct diet and food parcels that will improve body weight so that it can be interpreted in line with age.\u0026rsquo; \u0026nbsp;(Participant 2C)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e2.4 Subtheme 1.2.4: Referral to the law enforcement officers for security support.\u003c/p\u003e\n\u003cp\u003eReferral to law enforcement officers for security support emerged as a subtheme where participants reported that when they come across cases whereby HIV/AIDS orphans are being abused, they refer such cases to the police for further investigation and management. The following was echoed:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;If the orphan is abused, it is the prerogative of the social workers to involve the South African Police Services to establish the root cause of abuse and further management.\u0026rsquo;\u0026nbsp;\u003c/em\u003e(Participant 2F)\u003c/p\u003e\n\u003cp\u003eOne of the participants stated that they also involve the police when the needs of the children are neglected and said:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;One of the common cases is child neglect. Orphans are cared for by relatives when their parents pass away. So, if their stay with relatives is unstable, for example, they move from one family to another for two months with a cousin and two months with an uncle and aunt. It is challenging to decide who is entitled to a foster care grant. For example, the uncle took the foster care grant during the child\u0026rsquo;s stay at his home and used the funds to buy his own needs and ignored to buy clothes and other essentials for the orphan. Therefore, we involved the police and social workers to intervene.\u0026rsquo; \u0026nbsp;\u003c/em\u003e(Participant 3D)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOne of the participants emphasized the importance of law enforcement and said:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;There are recreational places adolescents and adults like visiting. In those places, some of them are killed, some raped, and some stay there for quite some time without coming back home. All these problems require people who can do follow-up, and in this case, police officers are the most relevant agents to do that.\u0026rsquo; \u0026nbsp;\u003c/em\u003e(Participant 3A)\u003c/p\u003e\n\u003cp\u003eAnother participant reported:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;You will find that some caregivers do not report cases of abuse of HIV/AIDS orphans. When we encounter such cases, we do a thorough assessment before involving social workers. She will have to confirm her assessment as well. After assessments, there will be a need to involve law enforcement officers\u003c/em\u003e\u003cem\u003e.\u0026rsquo; \u0026nbsp;\u003c/em\u003e(Participant 3D)\u003c/p\u003e\n\u003cp\u003eTheme 1.3: Facilitation of support groups for both caregivers and children orphaned by HIV/AIDS\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTwo (2) subthemes emerged from this theme, including adherence clubs and adolescent youth-friendly services.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e3.1 Sub-theme 1.3.1: Adherence clubs\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAdherence clubs were identified as the first subtheme in this study. The adherence clubs are reserved for all patients who are on chronic treatment. The initiative aimed to reduce overcrowding at the facilities by scheduling the exact dates for treatment collection for both parties. Adherence clubs assisted caregivers in readily\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003edisclosing their status to orphans without postponing. One of the participants indicated:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;The Department of Health has introduced a project called Adherence Clubs. In the cases of both caregivers and the orphan taking treatment, for example, chronic treatment and ART, we schedule the same follow-up dates for both. The caregivers benefit from this project of adherence clubs because they do not struggle to disclose their HIV status to the orphans. If the HIV/AIDS orphan asks questions, the caregiver just responds shortly by saying, \u0026lsquo;I am also taking treatment\u0026rsquo;. Most of the time, we encourage caregivers to take their medication at the same time as the orphans. There has been huge progress regarding disclosure since this initiative was implemented.\u0026rsquo; \u0026nbsp;\u003c/em\u003e(Participant 3B)\u003c/p\u003e\n\u003cp\u003eOne of the participants elaborated more on the terms of reference of adherence clubs. \u0026nbsp;They also address the needs of patients who are on other treatments. She said:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;We have initiated adherence clubs that are yielding positive results in the villages. These adherence clubs are not only for people who are HIV positive. They are for all chronic patients. They end up seeing each other at the clubs. We pack treatment according to a patient\u0026rsquo;s needs so no one can judge another regarding their treatment. As a result, it makes things easier for us. We don\u0026rsquo;t write about the disease that one suffers from nor the treatment that individual takes. During visits to adherence clubs, we give health education on specific topics. It is effective and impacts caregivers, and they become free from stigma and discrimination.\u0026rsquo; \u0026nbsp;\u0026nbsp;\u003c/em\u003e(Participant 1C)\u003c/p\u003e\n\u003cp\u003eThe club has played a fundamental role in improving adherence to treatment and the attitude of the community towards caregivers of HIV/AIDS orphans. The following was echoed:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;The club has improved adherence to treatment because it facilitates the process of patients accepting themselves. As caregivers of orphaned children, adherence clubs have helped to reduce the stigma and discrimination. The club has made all categories of people collecting treatment to relax after noticing that they are not alone in taking chronic treatment.\u003c/em\u003e\u0026rsquo; \u0026nbsp;(Participant 2F)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;3.2 Subtheme 1.3.2 Adolescent Youth Friendly Services (AYFS)\u003c/p\u003e\n\u003cp\u003eThe AYFS emerged as the subtheme in this study. The participants indicated they started a support group for adolescents at the facilities. The support group also discusses activities such as health education and other issues affecting adolescents\u0026apos; health. One of the participants mentioned: \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;Yeah, the other point we did not mention is that we also have teenager clubs. We invite them, and they can come along with caregivers to the clinic. We set a date and time, and when they arrive, we carry out activities with them, including how to get treatment and the importance of adhering to treatment. The adolescents are bound to come along with caregivers, and I think the initiative is productive.\u0026rsquo; \u0026nbsp;\u003c/em\u003e(Participant 1D)\u003c/p\u003e\n\u003cp\u003eThe main aim of initiating adolescents\u0026rsquo; clubs was to create a platform where matters that are related to HIV and affect the health of adolescents are ventilated. \u0026nbsp;One of the participants echoed the following:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;The main purpose of this teen club is to make sure that these teenagers accept their status and that they can teach those who are not HIV positive about the disease and to accept the status if the outcomes of HIV counselling and testing are positive. Again, teenagers\u0026rsquo; understanding of the disease makes the lives of caregivers very easy because caregivers sometimes struggle to convince teenagers to accept their status; therefore, teen clubs play a major role in motivating both teenagers and caregivers. There will be a good working relationship at home, and confidentiality will not become an issue when the child is affiliated with teen clubs.\u0026rsquo; \u0026nbsp;\u003c/em\u003e(Participant 1C)\u003c/p\u003e\n\u003cp\u003eThe teenagers are also advised to attend with caregivers of HIV/AIDS orphans, and the sessions that are conducted regularly boost their confidence. One of the participants echoed the following:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;At the AYFS, we capacitate adolescents with knowledge and skills regarding different conditions like HIV, STIs, and other chronic conditions. The sessions empower them with knowledge that guides them on how to conduct themselves when they have tested HIV positive. It also assists caregivers in disclosing their HIV status to children on time. If there is a delay in disclosure, children will start asking the caregiver many questions like \u0026lsquo;What is the medication that I am taking? Why am I taking the medication?\u0026rsquo; This will embarrass the caregivers, but this will ultimately compel the caregivers to disclose their HIV status to the child.\u0026rsquo; \u0026nbsp;\u003c/em\u003e(Participant 3E)\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study aimed to explore and describe the support provided by OTLs to the caregivers of HIV/AIDS orphans. To our knowledge, this study is a new contribution to the body of knowledge. The objective of this study was successfully met, and three\u0026nbsp;(3) main themes emerged from this study, namely the conduction of home visits to the caregivers of HIV/AIDS orphans, the coordination of multidisciplinary teams for support, and the\u0026nbsp;facilitation of support groups for both caregivers and HIV/AIDS orphans.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study revealed various support that is provided by OTLs to caregivers of HIV/AIDS orphans. Conducting home visits at the homes of the caregivers of HIV/AIDS orphans emerged as the primary theme, and subthemes were also identified in this study. Many of the OTLs reported that conducting home visits assisted them in identifying orphaned children not adhering well to medication. In such cases, OTLs assigned CHWs to implement directly observed therapy (DOT) on caregivers who are not giving orphaned children medication accordingly. Researchers defined DOT as a strategy that non-healthcare professionals use to observe whether the patients take treatment [42].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe findings of this study are consistent with the outcomes of the study conducted in Zimbabwe that reported that nurses involved CHWs when there were instances of ART non-adherence among HIV/AIDS orphans [43]. The authors went on to establish that during home visits, CHWs work closely with caregivers to identify any barriers that might prevent adherence to medication.\u0026nbsp;Following this results from a systematic review and meta-analysis also confirmed that DOT was beneficial to people who were more non-adherent to ART [44]. The authors also suggested that when employing DOT on people who exhibit non-adherence behavior, steps should be taken to ensure adherence.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThese steps of ensuring adherence to ART were evident in the study conducted in Zimbabwe,\u0026nbsp;CHWs visited the caregivers of HIV/AIDS orphans at home to follow up on matters that arose from scheduled clinical appointments and provide them with adherence support [45]. Existing literature and the current study categorically described the importance of the DOT strategy. Within the context of this study, the strategy improved adherence among HIV/AIDS orphans and capacitated caregivers with skills on how to maintain and sustain adherence.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEach one of the OTLs was obliged to adopt one HIV/AIDS orphan from each family and employ a holistic approach to ensure that the needs of that orphan are well taken care of. In line with the literature, the study conducted in\u0026nbsp;SA revealed that CHWs used a community-based intervention strategy to supervise caregivers of HIV/AIDS orphans on medication giving by visiting them weekly in their respective households [46]. Similar findings were reported in Uganda, where the Grandparents Action Support Project (GAS) was established to enhance the capacity of older caregivers to provide care to HIV/AIDS orphans and to improve the overall welfare of the families taking care of these children [47].\u0026nbsp;This study\u0026apos;s evidence demonstrated the strategy\u0026apos;s broad benefits, including the development of caring abilities for caregivers of HIV/AIDS orphans. The adopt-a-child approach has made it easier for OTLs, CHWs, caregivers, and HIV/AIDS orphans to have healthy relationships.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRoutine blood and growth monitoring played a fundamental role in assessing viral suppression among HIV/AIDS orphans. In concurrence, the cross-sectional study conducted in Tanzania reported that the households of caregivers of HIV/AIDS orphans that were monitored by Community case workers (CCWs) were more likely to be virally suppressed than those who did not [48]. The authors continued by asserting that there was a 149-fold increase in the likelihood of viral suppression in HIV/AIDS orphans who adhered to ART at a rate of \u0026gt;95% compared to those who did not. In this study, the OTLs visited HIV/AIDS orphans daily who did not thrive well or were malnourished.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDuring home visits, the OTLs assess how caregivers give medication and other aspects of a healthy lifestyle. After three (3) months, OTLs take routine blood monitoring to assess if the viral load is being suppressed and if the CD4 count is going up, as both are elements of growth monitoring and medication adherence. The literature revealed that orphaned children with viral suppression always present with improvement in clinical well-being, weight gain, and reduction of opportunistic infections [49]. Researchers whose focus was on low- and middle-income countries viewed viral load monitoring as a useful tool for identifying children living with HIV who require extra adherence assistance, minimizing regimen switching, and maintaining treatment alternatives [50]. \u0026nbsp;Based on the findings of this study and existing literature, we assume that optimal adherence to ART play is of paramount importance to improve CD4 count and suppress the viral load of HIV/AIDS orphans. It is evident in this study that OTLs had measures in place to support caregivers to sustain adherence.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAnother interesting finding revealed by this study was that the OTLs were responsible for providing caregivers of HIV/AIDS orphans with any kind of support during disclosure. \u0026nbsp;In line with previous research, a qualitative study carried out in the Eastern Cape of South Africa found that healthcare workers (HCWs) used a variety of techniques to assist caregivers with disclosure [51]. These included talking with caregivers to find out what their primary disclosure challenges were and teaching them how to disclose and handle the emotional responses of children after disclosure [51]. The cross-sectional survey about health care workers (HCWs) perspectives on disclosure to HIV-infected children conducted in Gauteng and Mpumalanga Provinces of South Africa revealed different results regarding who is entitled to disclose [52]. According to the survey, 48,5% of respondents felt that caregivers should take the initiative to disclose, 42.7% believed that caregivers and HCWs should share responsibility for disclosure, and 8.8% said that HCWs should take the lead in disclosure [52].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eUp to now, it is not clear about who should conduct disclosure between HCWs, and caregivers based on existing literature. Contrary to the results of the current study, a qualitative study carried out in Zimbabwe revealed that most community leaders and healthcare professionals believed that healthcare personnel were the best individuals to disclose HIV status to children who are infected [53]. Similarly, a qualitative study conducted in Zimbabwe discovered that most adolescents preferred disclosure to take place in front of HCWs in a clinical setting since they have the professional abilities to handle any potential discomfort and have access to reliable information [54]. We therefore recommend that there be standardized rules in place that specify the relevant stakeholder to disclose HIV/AIDS to children living with HIV, based on the findings of the current study and the literature that has already been published. The\u0026nbsp;OTLs further used multidisciplinary teams (MDT) as a source of support to the caregivers of HIV/AIDS to address various needs that require professional intervention. The multidisciplinary team refers to a group of different disciplines working together to improve the health and well-being of individuals [55]. The Elizabeth Glazier Paediatrics AIDS Foundation (EGPAF) guidelines indicate that if healthcare workers find caregivers who are reluctant to disclose their status to HIV/AIDS orphans, they must refer them to either social worker, nurses, psychologists, and other professionals for further counselling and support [56]. Within the context of this study, OTLs referred caregivers who had difficulty disclosing their HIV status of HIV/AIDS to psychologists for counselling and support.\u0026nbsp;The quantitative study conducted by Nicastro et al. provided evidence in support of this finding, revealing that psychologists employed family group psychotherapy as a means of facilitating disclosure to families of children living with HIV [57]. The quality of life and overall well-being of orphaned children were found to be enhanced by group psychotherapy, which also decreased the children\u0026apos;s anxiety levels and boosted their resilience.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCaregivers who were eligible to apply for social grants and did not have relevant documents were referred to social workers by OTLs for assistance. This finding agrees with the study conducted in SA, where social workers assisted orphans who did not have birth certificates to apply for social grants [58]. The author further reported that social workers also assisted orphans who did not have birth certificates to be admitted to schools. Consistent with previous studies, the study conducted in Zimbabwe reported that the Department of Social Welfare assisted caregivers in paying school fees and medical bills for HIV/AIDS orphans [56]. \u0026nbsp;On the contrary, the qualitative study conducted in NWP, SA whereby caregivers of HIV/AIDS orphans were complaining about a lack of support from the social workers [59]. Furthermore, the authors claimed that one of the caregivers waited for the assistance of social workers to apply for a foster care grant for more than a year. Existing literature reported that the Department of Social Development in South Africa acknowledged that insufficient numbers of available social workers make it difficult to deliver social services where they are needed [60,61]. The authors further revealed that social workers simply cannot deal with hundreds of thousands of foster care placements on top of the other services they need to provide [60,62]. Based on the evidence of the current study and existing literature, we suggest that OTLs should collaborate with social workers to ensure the smooth running of the services that they render to caregivers.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHIV/AIDS orphans presenting with malnutrition and failure to thrive (FTT) were referred to dieticians for nutritional support. As defined by [63]. malnutrition is when people receive insufficient or excessive amounts of specific nutrients, which can negatively impact their health and result in an inability to thrive. According to [64] malnutrition is the most common reason children do not grow as well as they should. Similarly, the literature review demonstrated that ready-to-use therapeutic meals (RUTFs) improved the way severe acute malnutrition was treated in children living with HIV/AIDS by giving them access to foods that promote fast weight gain and are safe to use at home [65,66].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn addition, a study conducted in Zimbabwe discovered that children with HIV who were given nutritional supplements by RUTFs for ten months, between the ages of twelve and thirty-six months, gained more weight of 51.2% than children who were not infected (26.0%) [67,68]. The findings of this study support existing literature that children living with HIV who were malnourished and placed on nutritional supplements were showing huge progress. In this study, dieticians administered nutritional supplements for a certain period to bolster the weight of the orphans who were malnourished, and food parcels were provided for the entire family. \u0026nbsp;This study described the support that should be given to caregivers if they discover instances of abuse and neglect involving HIV/AIDS orphans. The concepts \u0026quot;abuse\u0026quot; and \u0026quot;neglect\u0026quot; describe a scenario where a parent or caregiver causes physical, sexual, or psychological harm to children [69].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSuppose OTLs discover that an HIV/AIDS orphan has experienced abuse or neglect of any kind, whether it be psychological, emotional, physical, or sexual; in such cases, they should consult social workers to conduct an assessment and refer the case to law enforcement officers. Social workers\u0026rsquo; responsibilities include conducting thorough assessments, offering initial counselling, drawing an intervention plan, and making therapy referrals [70]. In the study conducted in KwaZulu Natal province of South Africa social workers were not involved in the incident that involved an orphan who was sexually abused [71]. \u0026nbsp;Despite the efforts made by the orphan child to report the incident to the caregiver, the sexual abuse incident continued. The orphan child decided to escalate the incident directly to the teacher at school who assisted her in reporting that to the law enforcement department. Consequently, the arrest of the perpetrator was affected by law enforcement officers however, this incident did not sit well with the caregiver who assaulted the orphan child for reporting the incident to the law enforcement officers [71].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe data reported here appear to support the assumption that orphaned children are sometimes not saved because caregivers who are supposed to offer them full protection are involved in the same acts of abuse against the orphaned children. A reasonable approach to tackle this issue could be to actively involve social workers as they are trained to handle such incidents. The effectiveness of the involvement of social workers in incidents of abuse of children has been exemplified in a study conducted in the Western Cape province of South Africa [66]. Children who were abused by the primary caregivers were removed from their care and placed in child and youth care centers (CYCC) [72]. Alternatively, the involvement of the social workers by OTLs could also aid in identifying people from the family who can foster the orphaned children who are found to be abused by the caregivers as reported by the current study. This action can assist in ensuring that the physical, psychological, and emotional well-being of the orphaned children are safeguarded. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAnother interesting finding reported by this study was the use of adherence clubs and adolescent youth-friendly services by OTLs to improve the relationship between caregivers and HIV/AIDS orphans. This study highlighted that the Department of Health (DoH) established adherence clubs (ACs) throughout SA. Adherence clubs support cross-government initiatives to improve population health and well-being. The purpose of ACs is to accommodate the increasing number of stable patients undergoing treatment, guarantee the quality of care, and lessen the workload on healthcare personnel in the facilities [73]. The ACs are not explicitly used for HIV/AIDS but for other chronic conditions as well. Consistent with existing literature, a study conducted in Mpumalanga on community-based adherence clubs indicated they played a crucial role in reducing overcrowding in healthcare facilities, defaulter rates, improving treatment adherence, and reducing stigma and discrimination [74]. These results are similar to those reported in the study conducted in Haiti whereby the Kids Club program assisted caregivers and children living with HIV with psychosocial development and well-being through group interaction [75].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIt has been reported that the Kids Club program was crucial in giving orphaned children the educational opportunities they needed to overcome their shyness, boost their self-esteem, give them encouragement and hope, and bring pleasure into their lives. Individuals who disclosed to the club that they were HIV-positive discussed how being a part of it had improved their knowledge of the virus, their ability to maintain their health, and their outlook on life [75]. Moreover, caregivers also reported how treatment treatment-taking behavior of orphaned children who attended the Kids Club improved. Similar results were reported in a recent study that\u0026nbsp;the ACs smoothened the relationship between caregivers and HIV/AIDS orphans.\u003c/p\u003e\n\u003cp\u003eThe OTLs further used adolescent youth-friendly services (AYFS) to educate orphaned adolescents about topics that affect their health and well-being. The findings of this study are aligned with previous studies that reported that peer support groups for adolescents and family clubs assisted adolescents in disclosing their status to significant others [76]. The author further reported that the initiative provided the caregivers of HIV/AIDS orphans with the opportunity to acquire more knowledge and skills on how to care for adolescents living with HIV, treatment adherence, and coping with stigma and discrimination. Similarly, a qualitative study conducted in five primary healthcare facilities in the SA revealed the effectiveness\u0026nbsp;of a psychosocial support intervention (PSS) for adolescents on ART [77]. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis initiative was implemented in an adolescent-friendly and safe space in the clinics in the form of social clubs. Interestingly, the authors stated that the PSS intervention promoted treatment adherence through peer support, health education, and relationships between adolescents, caregivers, and healthcare providers [77]. Another significant finding reported by the same authors was that the PSS intervention expedited full disclosure of HIV status to adolescents was also expedited by PSS intervention. Taken together, this finding supports the current study by highlighting the significance of support groups in reducing stigma and discrimination against caregivers and orphaned adolescents. Both studies further revealed the importance of support groups by harnessing the caring environment of the caregivers. In support of this finding, a qualitative study conducted in NWP of SA revealed that social clubs play a significant role in creating a supportive caring environment for caregivers of HIV/AIDS orphans by improving their psychological and emotional well-being [78]. To\u0026nbsp;date, the success of AYFS has enhanced caregivers with multiple skills in how to care for HIV/AIDS orphans.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e5. Limitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRecruitment of OTLs was challenging because the WBPHCOT program is championed by retired nurses due to the shortage of nurses in the NWP of SA. During data collection for this study, their contracts were expired therefore it was not easy to get hold of the OTLs.\u0026nbsp;\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe researchers struggled with the recruitment of the OTLs because the PHC re-engineering program is championed by retired nurses whose contracts with the DoH had expired.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor Contributions:\u003c/strong\u003e BJM formulated the title, BJM, was responsible for the methodology and BJM was responsible for data collection, BJM, SM, MD, and MM analyzed data, BJM wrote the draft, SM, MD, and MM reviewed and edited the manuscript.\u003cstrong\u003e\u0026nbsp; \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e This study was funded by the Health and Welfare Sector Education and Training Authority (HWSETA) however, North West University (NWU0 will be responsible for the publication fee.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInstitutional Review Board Statement:\u0026nbsp;\u003c/strong\u003eThe study was conducted by the Declaration of Helenski and approval to conduct the was granted by the North West University Health Research Ethics Committee (NWU-00196-21-A1. Before conducting the study, permission was obtained from the North West Province Department of Health.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed Consent Statement:\u0026nbsp;\u003c/strong\u003eAll processes to obtain informed consent were adhered to, and the participants were told about their right to voluntarily participate and withdraw at any time when the need arose. The study was approved by North-West University (NWU) Health Science Research Ethics\u0026nbsp;(NWU-00196-21-S1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement:\u003c/strong\u003e Data collected in this study is not available to the public. Only the researcher and study leaders have access to it. Moreover, the data are not publicly available due to privacy regulations. Currently, it is kept on a password-controlled computer to maintain confidentiality. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments:\u003c/strong\u003e The authors of this article would like to convey their undivided gratitude to the participants of this study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of Interest:\u003c/strong\u003e None\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eFoster G, Levine C, Williamson J, editors. A generation at risk: The global impact of HIV/AIDS on orphans and vulnerable children. Cambridge University Press; 2005 Sep. p. 12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBurkholder M. The Impact of HIV/AIDS on Orphans in a South African Context 2019. Orphans and Vulnerable Children Student Scholarship. 5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKarimli L, Ssewamala FM, Ismayilova L. 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Adultification, neglect and sexual abuse at home: Selected narratives of orphaned girls in KwaMashu, South Africa. Children \u0026amp; Society; 2023 Jan. p. 22.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHope J, Van Wyk C. Intervention strategies used by social workers in emergency child protection. Soc Work. 2018;54(4):421\u0026ndash;37.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFl\u0026auml;mig K, Decroo T, van den Borne B, van de Pas R. ART adherence clubs in the Western Cape of South Africa: what does the sustainability framework tell us? A scoping literature review. J Int AIDS Soc. 2019;22(3):e25235.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTshuma N, Mosikare O, Yun JA, Alaba OA, Maheedhariah MS, Muloongo K, Nyasulu PS. Acceptability of community-based adherence clubs among health facility staff in South Africa: a qualitative study. Patient preference and adherence. 2017 Sep 11:1523\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSettergren SK, Philippe R, St. Louis J, Segaren N, Boisson S, Lewis T, D\u0026eacute;sinor O, Fran\u0026ccedil;ois K. Importance of support groups to the health and well-being of vulnerable children and young people living with HIV: a case study of the Kids Clubs program in Haiti. BMC Health Serv Res. 2021;21:1\u0026ndash;2.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRencken CA, Harrison AD, Mtukushe B, Bergam S, Pather A, Sher R, Davidson BJ, Carrihill M, Matiwane M, Kuo C, Gal\u0026aacute;rraga O. Those people motivate and inspire me to take my treatment. Peer Support for Adolescents Living With HIV in Cape Town, South Africa. J Int Association Providers AIDS Care. 2021;20:1\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOkonji EF, Wyk BV, Hughes GD, Mukumbang FC. Implementation of a Psychosocial Support Intervention for Adolescents on Antiretroviral Treatment: Challenges and Experiences from Ehlanzeni District, South Africa. J Int Association Providers AIDS Care (JIAPAC). 2022;21:23259582221121094.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMolato BJ, Moloko-Phiri SS, Koen MP, Matsipane MJ. Coping mechanisms used by caregivers of HIV/AIDS orphans in North West Province, South Africa, 2024b [Unpublished].\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Caregivers, children orphaned by HIV/AIDS, outreach team leaders, support","lastPublishedDoi":"10.21203/rs.3.rs-4296065/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4296065/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThe human immunodeficiency virus (HIV) and acquired immunodeficiency deficiency syndrome (AIDS) epidemic have left an overwhelming impact on communities worldwide, particularly in Sub-Saharan Africa, where its effects on family structures are particularly pronounced. Caregivers of children orphaned by HIV/AIDS encounter challenges in fulfilling their caring duties. Consequently, they rely on the outreach team leaders (OTLs) for support to care for HIV/AIDS orphans.\u003c/p\u003e\u003ch2\u003eAim\u003c/h2\u003e \u003cp\u003eThis study aimed to explore and describe support provided by OTLs to caregivers of children orphaned by HIV/AIDS in the North West Province of South Africa.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThe exploratory, descriptive, and contextual design was used to realize the objectives of this study. The study was conducted in five local municipalities in the Ngaka Modiri Molema district of the North West Province of South Africa. Ward-based outreach nurses were participants in the study. Semi-structured focus group interviews were used for data collection. Thematic analysis was used to analyze data. Throughout the study, ethical principles were adhered to. The study also adhered to four trustworthiness principles: credibility, confirmability, transferability, and dependability.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThree main themes emerged from this study: the conduction of home visits to caregivers of HIV/AIDS orphans, the coordination of a multidisciplinary team for support, and the facilitation of support groups.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe study revealed support provided by OTLs to the caregivers of children orphaned by HIV/AIDS. Caregivers benefitted from the support provided and, therefore, experienced less stigma. Moreover, discrimination was reduced, disclosure was done on time, and medication adherence improved.\u003c/p\u003e","manuscriptTitle":"Support provided by outreach team leaders to caregivers of HIV/AIDS orphans in the North-West Province of South Africa","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-05-08 03:21:24","doi":"10.21203/rs.3.rs-4296065/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-06-17T05:59:01+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-06-12T19:15:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"211728550928135283851913313035208991227","date":"2024-06-02T16:09:15+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-05-13T12:58:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"241068258973196719917860570123454145571","date":"2024-05-06T05:51:31+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"261156485259663356652976312996166904783","date":"2024-05-02T17:49:08+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-05-02T14:50:57+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-05-02T09:33:52+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-05-02T09:10:22+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nursing","date":"2024-04-20T06:10:19+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5db00dc1-deb9-45f4-a72b-5a9704756ee8","owner":[],"postedDate":"May 8th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-09-02T16:05:44+00:00","versionOfRecord":{"articleIdentity":"rs-4296065","link":"https://doi.org/10.1186/s12912-024-02282-4","journal":{"identity":"bmc-nursing","isVorOnly":false,"title":"BMC Nursing"},"publishedOn":"2024-08-31 15:57:06","publishedOnDateReadable":"August 31st, 2024"},"versionCreatedAt":"2024-05-08 03:21:24","video":"","vorDoi":"10.1186/s12912-024-02282-4","vorDoiUrl":"https://doi.org/10.1186/s12912-024-02282-4","workflowStages":[]},"version":"v1","identity":"rs-4296065","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4296065","identity":"rs-4296065","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}