Study design, study site and study populations
Data were extracted from the clients’ service utilisation component of a larger data set that had been generated to provide baseline information on FSW, MSM and PWID for programmatic purposes. Data were generated by use of a sequential mix-method approach, wherein findings from the quantitative data were explored further by using qualitative data.
Data were collected from a sample of FSW, MSM and PWID residing in four of the 36 states in Nigeria: Enugu, Nassarawa, Benue, and Akwa-Ibom. The study sites were limited to these states because the data were to be used to plan and implement HIV prevention programmes for the target populations in them as part of a targeted intervention for key populations funded by the Global Fund for AIDS, Tuberculosis and Malaria. The intervention in the four states was named the Enhancing Key Population Intervention in Nigeria through Capacity Development (EKPIN) project. The study adopted the client-centred access to health care framework developed by Levesque and colleagues . Experience of care dimensions of the World Health Organisations quality of care framework for maternal and newborn health care was integrated into the theoretical framework for the design of this study so it can address the quality of care issues .
All study participants were 18 years of age or older and provided written consent for participation. The extracted data consisted of quantitative and qualitative data on clients’ satisfaction with services offered by the public health sector and the peer-led service organisations.
Field workers were selected on the basis of their competence and experience. The workers were also trained before data collection commenced and were rigorously supervised during data collection. During the project, all field workers uploaded the quantitative data and transmitted audio-recordings of the interviews daily. The study coordinator reviewed documents and sought clarification and rectification promptly. The study co-PI also reviewed samples of the data.
The Institute of Public Health Institutional Review Board gave ethical clearance for the conduct of the study (IPHOAU/12/268). Study participants were duly informed about the objectives of the study, risk and benefits, voluntary nature of study participation, and freedom to withdraw from the study at any time. Written consent was obtained from all participants. No participant identifiers were collected. The research outcomes were shared with 61 representatives of the MSW, FSW and PWID communities and with policy makers and HIV programmers for validation of results.
Data were collected by community members in locations that were considered safe and private. In all the states, a peer-led non-governmental organisation setting was used for data collection except when the respondent preferred an alternative spaces. Privacy and confidentiality of participants was ensured throughout the study. All study participants signed an informed consent form, were provided with educational material on prevention and treatment of HIV, received ₦2, 000 ($11.50) for transportation reimbursement, and were given condoms and lubricants.
This aspect of the study sought to identify the proportion of FSW, MSM and PWID who had accessed HIV prevention services from the public health facilities and peer-led initiatives and assess their their level of satisfaction with these services.
A standard sample-size calculation approach for cross-sectional study was used to determine the sample size for the study using WINPEPI software ; a minimum sample of 500 study participants was required (125 participants per state). A minimum of 50 FSW, MSM and PWID were to be recruited from each state.
Participants’ recruitment and data collection
Study participants were recruited between April and June 2015 from a minimum of two different parts of each state that had been mapped to have clusters of MSM, FSW and PWID. Decisions on the site for study participants was made based on the report of the key populations estimated size . The target was 25 FSW, 25 MSM and 25 PWID recruited from each of the two sites in each of the four states.
Interviewers administered a semi-structured questionnaire developed in English, to study participants. The study instruments were questions that were adapted from the instruments used in the National AIDS and Reproductive Health Survey. Key words and phrases, especially sensitive ones, were translated to the languages of each selected community and collected in a list generated during the training of interviewers. Interviewers used this material as a reference when in the field. A similar technique had been used for past national reproductive health survey [21,22,23,24,25] and the study by Folayan et al. .
First, study participants were asked if they had used public or peer-led facilities to access HIV prevention services. Those who had used services where then asked about their level of satisfaction with the services, using a 5-point likert-like scale: 1, very dissatisfied; 2, satisfied; 3, neutral; 4, satisfied; and 5, very satisfied. For the purpose of analysis, the categories ‘satisfied’ and ‘very satisfied’ were were collapsed into ‘satisfied, and ‘dissatisfied’ and ‘very dissatisfied’ were collapsesd into ‘dissatisfied.’ Respondents stated how satisfied they were for three service quality indicators: a) extent to which service providers listened to their problems and concerns; b) extent to which service providers assured them of confidentiality and privacy; and c) extent to which service providers respected their rights as a service recipient.
Next, respondents who had accessed HIV prevention services in public or peer-led organisations were asked to identify barriers to accessing these services: distance to services, cost, confidentiality, waiting time, hours of operations, and staff attitude. Respondents also had the option of identifying if they had perceived no barrier and to list barriers to accessing services beyond those specified in the questionnaire. Finally, respondents were asked about their willingness to continue to seek HIV prevention care in the public or peer-led facilities, or if they would rather seek services elsewhere.
Data collection procedure
Four field workers and focal persons for MSM, FSW and PWID received a three-day training on the study objectives; methodology, including ethical approach to data collection; and community-entry procedures. Field workers had prior experience conducting national reproductive health surveys and understood the local language and target community in each site. The field workers and focal persons pilot-tested the instrument and made recommendations for revisions before its printing. For each site, a local community guide was designated to facilitate community mobilisation and community entry processes. The guides were instructed in the study objectives and methodology; in making initial contacts with non-government organizations that were working with key populations in the state; in facilitating recruitment (locating key populations’ hot spots); and in booking study-related appointments. A one-day training was conducted for the local community guides. The study in each state was overseen by an experienced researcher who served as the state supervisor.
Study participants were recruited through exponential non-discriminatory snowball sampling . “Seeds” were recruited from members of the target groups, who then recruit other members from their personal networks. “Seeds” refer to the first contacts made for the snowballing; they were identified by state contacts engaged with planning of the study. Initially, three seeds were recruited, one for each key population. After filling the questionnaire, (s)he was asked to recruit a maximum of three more peers into the study. This recruitment procedure was expected to yield a wide spectrum of community members engaged in the study.
Univariate analysis was carried out to determine the proportion of respondents who had received HIV and sexual and reproductive health services from public sector or a peer-led service and their level of satisfaction and perspectives on barrier to services. Bivariate analysis was used to compare findings between the key population groups by use of chi-square test and Fishers exact test where appropriate. Analyses were conducted with SPSS. Statistical significance was specified at a p value less than 0.05.
This aspect of the study further explored key populations’ perceived barriers to accessing HIV services from public or peer-led HIV services. Forty in-depth interviews (10 per state) were conducted with leaders of key population communities and 16 (4 per state) focus group discussions with key populations. The sessions were audio-recorded, and hand-written notes were taken. Basic socio-demographic data were collected for the participants, and the research personnel developed a detailed debriefing note and a summary report immediately after each interview or discussion session.
Participants’ recruitment and data collection
Study participants recruited for the in-depth-interviews were community leaders who are highly knowledgeable on issues of key populations’ access to HIV prevention, treatment and care services. The community leaders in each state were identified through the national key populations secretariat. The leaders are persons who represent the communities in key strategic national and state policy and program meetings, and whom the communities recognise as their political representatives. The interviews solicited the participants’ perspectives about structural and other barriers to key populations’ access to HIV prevention service. The in-depth interviews were conducted with a semi-structured guide that was based on the study objectives, extant literature, and input from representatives of key populations.
With respect to the focus-group discussions, one individual session for each population (FSW, MSM and PWID) was held in each state, and one combined session of the groups was also held. Each session had 6–10 participants. The sessions started with an “ice breaker,” a short briefing on the EKPIN project, and an opportunity for participants to ask questions about the project and the research. A vignette was used to facilitate the discussions by allowing participants to project their views rather than personalise the discussion. For each session, the discussants were guided to develop the profile and identity of the individual to be discussed in the vignette. Thus, the names and sociodemographic profile of the individuals used for each vignette were appropriate for the focal key population group and the study location. The issues discussed were the same, however, in all the focus group discussions,
The qualitative data generated from the in-depth interviews and focus-group discussion included handwritten notes (brief field notes, summary notes and debriefing reports) and transcripts from audio recordings. In-depth analysis was conducted using the Atlas.ti software package. Three designated team members worked in collaboration with two expert qualitative data analysts to develop a codebook and guidelines suitable for use with Atlas.ti. A selected set of texts was double-coded by two analysts to establish intra-coder and inter-coder reliability – a quality control measure that was automatically generated by Atlas.ti. After this quality check was completed, the coding team discussed the coding discrepancies and resolved them by consensus during several face-to-face sessions. The process continued until inter-coder reliability was at least 80%. The remaining text then was coded by one analyst, with regular discussions among all the analysts to achieve standardisation and reliability. Themes for each of the questions were identified and a streamlined list of quotes developed.