Expert Interviews (Key Informant)

The key aim of this study was to understand how women perceived and experience the health care provider initiated routinely offered HIV testing scheme for women during pregnancy and childbirth. However, it was also necessary to conduct interviews with key informants who are directly involved in the implementation of the PMCT programme in Ethiopia to describe the practice and relationships that shaped women’s experience in their interactions with the health- care system.

Accordingly, in addition to the in-depth interview with the HIV positive women, 9 key informant interviews were conducted with key informants both in Mekelle and Ofla district (2 midwives, 2 nurses, 3 health extension workers). The perspectives provided by the health care providers are crucial for understanding the socio- political and cultural situations of the expansion and implementation of routine provider initiated ‘opt-out’ HIV testing approach in maternal health care settings. The expert interviews

146 were conducted towards the end of fieldwork to reflect on the findings from interview with women, and I have exerted maximum caution not to discuss the information collected from the women in the previous interviews. (See Appendix D) In Korem health centre interviews were made with the midwife (male) and a female nurse in the health centre who were responsible of handling both ANC and labour wards altogether while in Mekelle hospital one nurse from the antenatal care unit and one midwife (both female) from the delivery ward were interviewed. All of the in-depth interviews took place in their offices after work.

The letters that I had from the Tigray regional Bureau of Health and the authorization from the management of both health institutions facilitated my access to the experts although I was forced to endure many late hour cancellations of appointments by experts from Mekelle hospital. All expert respondents gave consent to be cited in the text, and where appropriate are cited by position. My first expert interview was with the midwife and nurse working in Korem health centre that have a direct responsibility of the implementation of the PMCT programme. During this interview with the health workers in Ofla district, I was confronted with unexpected events that they dictated me to conduct the interview together with a disguised that they have no time to do it separately. I agreed to their terms because I had already learned that there were only two of them in the health centre responsible for maternal health care and directly involved with the PMTCT services in the centre. Hence I had no chance to conduct the interview with others. The interview was conduct in late afternoon and took a total of two hours. During the course of the interview I noticed that the male midwife dominated the interview which made me to take conscious efforts to pose questions to the nurse participant to ensure that I did not missed any opportunity to gain two individual perceptions of the implementation of a routine ‘opt-out’ HIV testing approach in rural settings.

147 In addition, even though I thought I had made it crystal clear to the health care professional from Ofla district who participated in this research that I am just a doctorate student doing a research on issues of HIV testing for women during pregnancy and child delivery, I have noted that my key informant were not fully convinced that I have nothing to do with the health bureau or other organs of the regional government. As a result of this most of the information given by the experts were very much sensitized with the popular political terminologies and propaganda in the country. For example a statement ‘because our government is a democratic developmental government ... we , as an army for

development , are working day and night towards AIDS free generation...’ was commonly mentioned

by the key informants which I later on started to understand as it is their way of being politically correct. Despite my concerns, analysis of expert respondents’ interviews and their extended narratives revealed much about the ways in which the expert understood issues revolving HIV screening of women during pregnancy and delivery in rural settings from their own perspective.

The interview with health care professionals in Mekelle was conducted in a way I planned it. A midwife and a nurse participated in the interview individually. During the interview sessions I also noticed that they did not have any trouble taking me as just a doctorate student mainly due to the fact that I had had a prior social acquaintance with both of them. They already knew who I was. I believed that this has worked to my advantage.

As part of the key informant interviews, I also conducted an interview with three Health Extension Workers (HEWs). My first interview with the midwife and nurse in Ofla district opened access to conduct interview with three HEWs in relation to the HIV screening of women in the villages of that district. Without their help, it would have proven quite difficult to locate the HEWs, because the HEWs

148 normally work by visiting women door to door in the villages. Thus, the interviews with the HEWs was also fruitful as I was able to ask more specific questions about the follow up and mechanism adopted to ensure all pregnant women are screened for HIV in the rural areas.

4.4. 4 Field Diaries and Observations

I also generated data in the form of my field diaries. My field note comprises documentation and comment on the ‘content’ of the fieldwork, for example recording the time, location, respondent and key themes from an interview, alongside any additional comments arising from discussions taking place after the interview. I also documented the research process and used this to reflect on how the research project was progressing and on the possible reasons for any difficulties encountered. I found that my deconstructions of interviews recorded in the field diaries provided extremely useful both in the field and in the period of ‘writing up’ on return.

This study is also informed by data collected using non-participatory observation. I did the observation in Mekelle Hospital in the Integrated Maternal and Child Health Department. I sat in for seven ANC sessions to observe how HIV testing is offered to pregnant women as an integral part of the antennal health care service and the way the pregnant women responded to the offer. Three of the pregnant women were first time ANC visitors and the remaining came based on their appointment. HIV testing was not discussed between the 4 women probably because they have already taken the test and there was no point of discussion for the nurses. But for the three first–time clients HIV testing was offered by the nurses and two of them accepted automatically but one tried to refuse the testing but gave up quickly as discussed in the subsequent chapters.

149 I used a standardised checklist to observe the activities and communications in the ANC room. Despite the limited participation I was able to observe the most visible elements of the routine offering of HIV testing to pregnant women visiting the ANC by health care providers. The data collected included the setting arrangements in the room, the greetings and reception of the clients, the words exchanged between the patients and the nurses, body languages and non-verbal components of interactions were taken account of during the observational data generation that fed into the analysis and interpretation of interview data.