# Healthcare workers’ perspective about barriers and facilitators to pediatric HIV status disclosure in eastern Uganda using capability opportunity and motivation of behavior change model

## TL;DR

This study explores what helps and hinders healthcare workers in Uganda from supporting HIV disclosure to children and adolescents, using a behavior change model.

## Contribution

The study applies the COM-B model to identify multi-level barriers and facilitators to HIV disclosure in a high-HIV-burden setting.

## Key findings

- Limited training and unstable home environments were major barriers to HIV disclosure.
- Peer support and supervision were key facilitators for healthcare workers.
- Emotional rewards and checklists enhanced automatic motivation for disclosure.

## Abstract

HIV status disclosure by caregivers to children and adolescents living with HIV (CALH) remains a public health concern in countries with a high burden of HIV despite guidelines for healthcare workers (HCWs) to facilitate the process. This study explored barriers and facilitators to HIV disclosure at two referral hospitals in eastern Uganda focusing on the utilization of existing guidelines. In-depth qualitative interviews were conducted among all HCWs involved in the management of CALH at three pediatric HIV clinics. Research assistants collected data using a semi-structured interview guide designed based on the Capability, Opportunity, and Motivation of Behavior change (COM-B) Model. The audio-recorded interviews were transcribed verbatim, analyzed thematically, and categorized based on the COM-B and social-ecological models using the inductive content approach. Sixteen in-depth interviews were conducted among HCWs, including both males and females in equal numbers. The barriers to disclosure involved all five levels of the social-ecological model, while facilitators were at only three levels (individual, interpersonal, and institutional levels). Regarding the capability of HCWs to support disclosure, limited training affected their psychological (knowledge) and physical ability (skills), while awareness of responsibilities enhanced psychological ability. For opportunity, an unstable home environment, limited access to guidelines, and HIV-related stigma were barriers in physical and social environments, while peer support, teamwork, and orphanhood status were facilitators in the social environment. Limited health funding and lack of preparatory procedures affected reflective motivation, while delayed disclosure affected automatic motivation. Conversely, emotional reward and monitoring, checklists, and supervision enhanced the automatic motivation of HCWs toward disclosure. The findings highlighted several potentially modifiable factors that need to be addressed or reinforced to improve HIV disclosure and utilization of existing guidelines. These findings are key in informing stakeholders regarding the development of implementation strategies for improving pediatric HIV disclosure and utilization of existing guidelines in Uganda.

HIV status disclosure to children and adolescents is important for good treatment outcomes but remains a public health challenge in many countries grappling with a high burden of HIV infection regardless of the existing guidelines. This study was conducted among sixteen purposively selected HCWs to explore barriers and facilitators to HIV status disclosure to children and adolescents living with HIV in eastern Uganda. Qualitative interviews were conducted using a guide developed based on the Capability, Opportunity, and Motivation model of behavior change. Findings indicated that limited training affected both the psychological and physical ability of HCWs to support HIV disclosure, while awareness of responsibilities was a facilitator. An unstable home environment, limited access to guidelines, and HIV-related stigma were physical and social environment barriers, while peer support, teamwork among HCWs, and orphanhood status were social facilitators. Limited health funding, lack of preparatory procedure, and delayed disclosure affected reflective and automatic motivation, while emotional reward to HCWs and monitoring, checklists, and supervision were automatic motivators.

There is a need to design interventions that address these barriers and reinforce the facilitators to enhance the capability and motivation of HCWs to support disclosure and to improve the social and physical environments for disclosure.