The study was embedded in a wider demonstration project that aimed to integrate HBV care into routine HIV care delivery system, known as the “2for1” demonstration project. Aside from the feasibility and acceptability component being reported here, the project also had components of training healthcare workers on care and management of HBV infection whether as mono- or co-infection, developing pathways for HBV and HIV standalone clinics compared to integrated pathway and costing the pathways. The rest of the components are being written separately. It was implemented in two public health facilities, Arua regional referral hospital and Koboko district hospital, both located in North-Western Uganda. This region has a significant refugee population  and a high burden of HBV [5, 14]. Arua regional referral hospital is a higher level facility with a high patient volume and a 323 bed-capacity. It serves a population of 782,077 including districts of West Nile and Northern Uganda . Koboko hospital is a lower level facility which serves a population of 129,148 in a region that shares a border with both South Sudan and the Democratic Republic of Congo.
Study design and sample selection
The study utilized focus group discussions (FGD) and key-informant interviews (KII). In each facility, three groups of participants were purposively enrolled for FGDs;(i) a group of HIV-infected patients; (ii) a group of HBV-infected patients; (iii) a group of patients with HIV and HBV co-infection. This design yielded a set of 6 groups of participants with a mixed background regarding age, sex, ethnicity, socioeconomic status, religious, cultural and health beliefs. Yet, relative group homogeneity arising from a common chronic infectious illness would allow free interactions between participants and free expression of personal views relevant to the discussion . Key informants were consecutively selected and these included different cadres of health care providers. Participants were physically approached. In Arua, we interviewed 11 health care workers (HCWs), five of whom were female, while in Koboko we interviewed 9 HCWs, five of whom were female. The HIV-focus group in Arua had 8 participants, 4 of whom were female, in Koboko it had 10 participants, 4 of whom were female. The HBV-focus group in Arua had 10 participants, 5 of whom were female, in Koboko it had 7 participants, 3 of whom were female. The HIV/HBV-focus group in Arua had 11 participants, 5 of whom were female, in Koboko it had 6 participants, 2 of whom were female. Study participants were purposively selected from those who had prior experience journeying through either the HIV or the HBV care processes, or both for more than a year. Patients had to be attending the clinics at the study sites, while health care providers had to be working in either the hepatitis clinic or the HIV clinic. The study was introduced to patients who had come for services during the health education session, and those willing to join were consecutively selected until the required number was reached, per focus group. Health care workers who were most senior and had worked in the HIV or HBV clinics longest were selected, because they had experience with patient care processes. Focus group discussions were convened after patients had received care, because this was their preference.
Study tools and data collection
Data was collected prior to HIV/HBV integration and this was done at the respective health facilities. Semi-structured interview guides were used to guide both the KII and the FGD. Both the study objectives and theoretically-informed constructs of health intervention feasibility and acceptability [7, 17] guided the design of study tools. Each tool had a total of 15 open-ended questions distributed across two sections; perceived feasibility and acceptability. For perceived feasibility to integrate HBV into HIV care model we explored whether (i) integration is perceived to fit within the existing healthcare infrastructure, (ii) perceived ease of implementation of HIV/HBV integrated care, and (iii) perceived sustainability of integration. For acceptability of the integrated HIV/HBV care model, we explored whether the HIV/HBV care model is perceived as (i) suitable, (ii) satisfying and attractive (iii) there is perceived demand, need and intention to recommend its use. All study tools were translated and back translated into Lugbara and Akakwa for Arua and Koboko regions respectively. They were also piloted among attendees of outpatient clinics of the hospitals. A private room within each hospital setting was provided, where interviews with key informants and focus group discussions were conducted. Both the KIIs and FGDs were facilitated by two trained research assistants with expertise in qualitative interviewing. One facilitator moderated the discussion while the other managed the audio-recording. Both took notes during the sessions. Probing techniques were used to allow participants share complete information on issues that emerged. Data was collected until saturation was achieved. Back-up notes were taken during each interview or FGD and updated into descriptive narratives soon after the sessions. Interviews and focus group discussions took place in a private setting to ensure confidentiality. Individual interviews lasted about 50 minutes, while focus group discussions lasted about 90 minutes each.
Data from the audio recordings were translated into English and precisely transcribed by research assistants and one of the investigators. Care was taken to maintain meaning during transcription. We conceptually based our analysis on the framework analysis [18, 19]. Three investigators read the interview text several times to gain immersion into the data. Then, parts of text were condensed into meaning units and similar meaning units were compiled and given a code after discussion and agreement among the investigators. Coding process used both inductive method that generated emerging themes and deductive approaches, with pre-selected themes. Codes were then compared and sorted into categories. Interpretation of categories for latent meaning then led to emerging themes and sub-themes, which were presented with corresponding supporting quotes. The coding matrix has been provided as additional file 1.
Data collection and analysis was led by one female and 2 male researchers with relevant experience in qualitative research in public health. Authors JNM (MD, MS, PhD), CW (MPH) and DE (MHSR) performed the KIIs and facilitated the FGDs. They all had training in qualitative research and analysis methods and were study investigators. Interviewers greeted and introduced themselves to participants prior to the interview. Participants were not made aware of interviewers’ particular interests in the study, including whether or not they preferred HBV care integration. Individual researchers may however, have had undisclosed assumptions regarding when or how best to integrate HIV/HBV care. The COREQ guidelines were used and the checklist is provided as additional file 2.
The study received approval from Makerere University School of Medicine Research Ethics committee (SOMREC REC REF 2018 − 185) and Uganda National Council for Science and Technology (UNCST SS 4986) and carried out following the Declaration of Helsinki protocol. All study participants were provided with complete information about the study, and taken through a consenting process prior to study participation. Data was collected in a quiet private environment and information provided by participants was treated with confidentiality.