Counseling fatigue of HIV/AIDS counselor in Calabar, Nigeria
How to cite this article: Mgbekem MA, Oyira EJ, Ella R, Lukpata F, Armon M, Ntamu GU. Counseling fatigue of HIV/AIDS counselor in Calabar, Nigeria. Calabar J Health Sci 2019;3(1):16-24.
There is different perception of HIV/AIDS counselling fatique among counsellors of patients. This descriptive study assessed perceived HIV/AIDS counseling fatigue among HIV/AIDS counselors in Calabar, Nigeria.
Materials and Methods:
A total of 90 counselors were assessed using a 35-item questionnaire measuring a variety of counseling activities. Fatigue was ranked on a 5-point Likert-type scale. The counseling fatigue was categorized in five subscales: accessibility of clients for HIV Counseling and Testing (HCT), explains and facilitates, monitoring and follow through, trusting relationships, policies in counseling activities, and burnout responses.
The results showed that counselors’ perceptions on fatigue were mostly on accessibility of clients for HCT (Mean = 72.50, standard deviation [SD] = 6.124) with statistical significance of Chi-square calculated = 161.419, df = 5; P < 0.001, monitoring and follow through activities (mean = 71.80, SD = 11.23, Chi-square calculated = 31.223; df = 4; P < 0.001), and policies in counseling activities (mean = 66.0 SD = 9.62, (Chi-square calculated = 11.906, df = 6; P < 0.05). Explain and facilitate statistically and significantly correlated with age (r = 0.610, P = 0.000) and years of experience (r = 0.695, P = 0.000). Burnout responses were also statistically significant (Chi-square calculated = 144.000; df = 7; P < 0.001).
Findings show HCT counseling activities generally cause fatigue for counselors, however, explain and facilitate counseling activities correlated with age (20–29 years) and years of experience (1–2 years) as these were found to be more fatigued among the participants. The years of experience correlation could be attributed to lack of formal HCT counseling training reported by 20 (20%). Further research is needed to explore counselors’ perceptions of HIV/AIDS counseling fatigue in different cultures.
HIV Counseling and Testing (HCT) has been identified as a key component in preventing the spread of the infection and serves as the gateway to all other HIV interventions.[1-3] Certain authors[4-6] opined that counseling is a face to face communication where a counselor helps a client to identify, clarify, and resolve a problem to make an informed decision. HIV/AIDS counseling involves confidential dialogue between a client and a health worker aimed at enabling a client to evaluate the personal risk of HIV transmission, progression, and individual status to make decisions related to HIV and AIDS treatment where necessary.[1,3,7] The counselor therefore has the responsibility of helping a client to discover and make informed decisions about his/her life choices in relation to HIV. The counselor is thus faced with a task that demands high degree commitment and conscientiousness. In an attempt to accomplish these demands, the counselor finds himself/herself faced with lot of challenges that make him/her vulnerable to fatigue, with negative repercussions to counselor, employing organization, and clients. HIV/AIDS counseling is a sensitive issue that requires counselors to be highly skillful and tactful in handling counseling sessions to avoid embarrassment or psychological trauma to the client. Counseling of depressed clients creates challenges such as emotional trauma as the counselor continually face the ill-health, the suffering, and dying people, especially in resource constraint societies. The counselors may worry about their friends or family members or personally be at risk of HIV/AIDS from the work environment.
Counseling is one of the most stressful jobs performed by health-care professionals. Although counseling is a noble undertaking, it can exert psychological pressure on the counselors. HIV/AIDS counseling is particularly challenging and often generates anxiety, fear, and despondence in counselors due to the nature of HIV/AIDS disease, with its diverse impacts on individuals, couples, and family. Witnessing people suffer and die from HIV/AIDS- related illnesses especially in resource limited society could evoke worry in the counselor to the extent that they fail to function competently and professionally,[10,11] resulting in poor counseling outcome. HCT counseling involves legal issues, ethical dilemmas, autonomy, confidentiality, and personal rights demanding counselor’s understanding of the job implication.[12,13] Counseling in HIV/AIDS entails the counselor collecting and testing client’s blood after the initial counseling session to determine the HIV serostatus of the client. This process exposes the counselor to the danger of being infected not only with HIV but also other diseases such as Hepatitis and other blood-borne diseases. To prevent such occurrences, there is a need for utilization of networking activities that promote better care delivery to reduce fatigue.[4,14,9] Piko, Coyle et al., and Kruse et al. see fatigue (burnout) as a state of physical, emotional, and mental exhaustion reported by people who work intensively with other people in emotionally demanding situations like HIV counseling that requires repetition of counseling activities. HCT counseling activities causing exhaustion are grouped generally as attitudes, attending skills, counseling environment, and result reporting. In this study, however, they were grouped under the following subscale: Accessibility of clients for HCT activities, explain and facilitate counseling activities, monitor and follow through activities, trusting relationship in counseling activities, and policies in counseling activities. HIV counselors are an at- risk group for fatigue, considering the nature of the illness, the multifaceted needs of the client, the relative paucity of trustworthiness, available counselors’/counseling centers, and various psychosocial issues connected with HIV/AIDS.[18-20] Little is known in Calabar about counselor fatigue from the counselors’ perspectives. This study was therefore designed to assess counseling fatigue of HIV/AIDS counselors in Calabar.
Statement of problem
Challenging work can be a motivator to high performance or a source of stress.[3,21] Studies have identified and reported stressors correlated with HIV/AIDS care and its impact on healthcare workers.[7,8,22,23] Infection with HIV/AIDS has legal, ethical, and human rights implications. These issues are multi-faceted, complex, and encapsulated with stress as Kerr et al. observed especially when the counselors function in struggling health systems where workloads are high and resources are minimal. This assertion is buttressed by Manhas and Bakhshi who opined that in the current era of globalization, liberalization, and continual change, the basics of life are full of pressures and stress. In HIV/ AIDS counseling, the counselor’s role is to facilitate dialogue, persuasion and encourage the flow of adequate information on these issues to motivate client’s prevention and transmission of the infection to other individuals.[1,5] This process is very tasking considering society’s view on the infection. Stress is experienced even more for counselors new in the job and/or not experienced to handle many HIV counseling sessions. This process of communication in HCT is often associated with fatigue.[7,15-17] Harkin and Melby
Fatigue is a form of burnout that is associated with frustration. In HIV/AIDS counseling, fatigue arises from excessive demands for attention by clients, handling very ill, suffering and dying people, and worrying about being infected in the course of the care delivery.[14,28] Maslach et al. described fatigue as a multidimensional process with three central constructs: emotional exhaustion (feeling emotionally drained and exhausted by one’s work), depersonalization (negative or very detached feelings toward clients or patients), and reduced personal accomplishment (evaluating oneself negatively and feeling unsatisfied with positive job performance and achievements). In consideration of these constructs, it became imperative to assess HIV/AIDS fatigue among counselors in Calabar, Nigeria.
Objective of the study
The aim of the study was to assess counseling fatigue among HIV/AIDS counselors in Calabar, Nigeria. The specific objectives were to identify the fatigue provoking activities that HIV/AIDS counselors encounter, to determine the reasons for the fatigue, and determine the association between fatigue- provoking situations and the tasks performed.
There is no significant relationship between counselors’ fatigue and counseling activities.
MATERIALS AND METHODS
Lazarus and Folkman’s stress appraisal and coping theory guided this study. This theory focuses on what an individual actually thinks and does within the context of a specific encounter and how these thoughts and actions change as the encounter unfolds. These thoughts and actions are influenced by the person-environment relationship that often results in stress and eventually determines the coping ability of the person.
A 35-item structured questionnaire was developed by the researchers. The instrument was divided into two sections: socio-demographic data questions and counseling fatigue which were subdivided into six subscales, name: accessibility covering five questions, explain, and facilitate counseling activities questions, monitor, and follow through activities questions, trusting relationship in counseling activities questions, policies in counseling activities questions, and burnout responses among counselors questions. To ensure face and content validity, the questionnaire was given to a group of 5 nurse counselors in the University of Calabar involved in HCT/AIDS activities in the state. The instrument was then pretested on ten counselors not included in the study and a coefficient of 0.86 obtained showed the instrument reliability. A multistage sampling technique was used to select five institutions offering HIV/ AIDS counseling services in Calabar, while a simple random sampling technique was then used to choose 18 counselors from each health facility. Data were collected on less busy days suggested by the counselors.
Results were expressed as means and SD. Mann–Whitney analyses were performed to compare counselors’ activities with counseling fatigue and its dimensions. Spearman’s rank correlation was used to assess the relationship of counseling activities and fatigue with the variables mentioned above. Differences were considered statistically significant at P ≤ 0.05. SPSS version 20 was used for data entry and analysis.
Approval for this study was obtained from the Ethics Committee of Cross River State Ministry of Health. Permission was also obtained from the hospitals that the participants were recruited while informed consent was obtained from the participants after careful explanation of the aim of the study before the administration of the questionnaire. To ensure confidentiality and anonymity, neither the name of respondents nor the clinics were requested on the questionnaire. No physical or psychological risks were involved. The list of participants for sampling purposes is kept safe to ensure confidentiality and anonymity. The counselors were informed that they have the right to refuse to participate or withdraw from participation without penalty at any point.
The study enrolled a total of 90 respondents from different counseling units of the Heart- to-Heart Clinics in Calabar who met the inclusion criteria and provided written consent. The findings on socio-demographic data [Table 1] revealed that the majority of the respondents were females 51 (56.7%) while 39 (43.3%) were males. The median age was 35 years (35–50 years), 50 (55.6%) and 26 (28.9%) were between 30 and 39 years, 49 (54.4%) were Registered Nurses/Midwives/ Psychiatric nurses which showed their level of professional educational level. Counselors with 6 years and above counseling experience 40 (44.4%) were in majority followed by 3–5 years. Forty (44.4%) respondents said they had attended training at least 3 times a year, 32 (35.6%) attended once a year while 20 (20%) had not undergone any training.
|40 years and above||50||55.6|
|B. Sc/B. Ed||16||17.8|
|M. Sc and above||25||27.8|
|6 years and above||40||44.4|
|Thrice a year||40||44.4|
|Once a year||32||35.6|
Accessibility of clients for HCT [Table 2] showed that 65 (72.2%) of the respondents reported being fatigued in the course of assessing clients’ motivation for accessing any health facility for HCT, 70 (77.8%) agreed that counselors’ maintenance of confidentiality and ability to explain type of services offer influence HCT turnout among clients. Eighty counselors 80 (88.9%) reported being fatigued when determining clients’ waiting time to access HCT services since many of the clients can spend more than 2 h before being attended to at the HCT center, 85 (94.4%) said the number of counseling sessions handled (group or individual) was one of the fatigues provoking situations. The provision of sufficient information choosing words to explain vital HCT processes was reported not to be a source of fatigue by 55 (55.6%) respondents. Findings in this section were, however, statistically significant (Chi-square calculated = 161.419, df = 5; P < 0.001) with counselors’ fatigue.
|Variable||Fatigued F (%) Mean SD||Not Fatigued F (%) Mean SD||Total|
|(i) Assess clients’ motivation for accessing the health facility for HCT services||65 (72.2)||25 (27.8)||90 (100)|
|72.50 6.124||17.50 6.124|
|(ii) Ability to explain the type of services offered (formal hospital services stand-alone HCT centers, or mobile HCT using trucks, etc., Home-based)||70 (77.8)||20 (22.2)||90 (100)|
|(iii) Maintain clients’ confidentiality and provide information choosing words that clearly explain HCT processes||80 (88.9)||10 (11.1)||90 (100)|
|(iv) Counselors’ level of experience influence client waiting time determination on continuing with services in the facility||85 (94.4)||5 (5.6)||90 (100)|
|(v) Number of counseling sessions offered (Group or individual) and provision of appropriate information.||40 (44.4)||55 (55.6)||90 (100)|
Explain and facilitate counseling activities [Table 3] revealed that 77 (77.8%) said the process of explaining and discussing HIV testing issues and concerns, explain how HCT works and get client to undertake voluntary counseling and testing 72 (80%), provide pre-test information 74 (82.2%), discuss where testing is offered, answer questions, and perform test if consent is given 75 (83.3%) and giving test results, explain window period or positive living were reported as sources of fatigue by the respondents since this required patience, clear and repeated explanation of HCT to clients. These variables however were not statistically significant (Chi-square Cal = 10.150; Chi-square Cal tab 12.59, df = 6, P < 0.05).
|Variable||Fatigued F (%) Mean SD||Not Fatigued F (%) Mean SD||Total (%)|
|(i) Get information why HCT is needed and discuss HIV testing issues and concerns||70 (77.8)||20 (22.2)||90 (100)|
|71.80 11.23||16.43 2.99|
|(ii) Explain how HCT works and get clients go for VCT||72 (80)||18 (20)||90 (100)|
|(iii) Provide pre-test information and ensure understanding of the HCT process||74 (82.2)||16 (17.18)||90 (100)|
|(iv) Discuss where testing is offered, answer questions and perform test where possible||75 (83.3)||15 (16.7)||90 (100)|
|(v) Give test results, explain window the window period or positive living||77 (85.6)||13 (14.4)||90 (100)|
Monitor and follow through activities [Table 4] results revealed that 80 (88.9%) respondents were fatigued due to identifying clients’ locations in the communities for HCT services especially in the sub-urban areas, 70 (77.8%) attributed the fatigue to be due to bad roads, lack of transportation to track clients resulting to poor monitoring and follow-up. Discussing stigmatization and discrimination were reported by 55 (61.1%) to generate many issues, concerns and questions while 84 (93.3%) of the respondents said obsolete equipment/poor technical know-how (e.g., auto jet lancet) made work process tiring. The activities in this section were statistically significant (Chi-square calculated = 31.223, df = 4; P < 0.001).
|Variable||Fatigued F (%) Chi-square SD||Not Fatigued F (%) Chi-square SD||Total (%)|
|(i) Identifying client’s location in the community for HCT services is often stressful||55 (61.1)||35 (38.9)||90 (100)|
|71.80 11.23||17.50 6.124|
|(ii) Providing private and confidential services to prevent stigmatization and discrimination is often stressful||70 (77.8)||20 (22.2)||90 (100)|
|(iii) Bad roads, transportation to track clients and carrying bags and boxes with testing supplies contribute to poor monitoring and follow-up||80 (88.9)||10 (11.1)||90 (100)|
|(iv) Obsolete equipment/poor technical know-how of the equipment (e.g., auto jet lancet) makes work tiring||84 (93.3)||6 (6.7)||90 (100)|
Trusting relationship in counseling activities [Table 5] showed that disclosure of positive results is often very difficult 50 (55.6%) while discordant result disclosure is one of the hardest sessions to handle 68 (75.6%). Majority of the respondents 70 (77.8%) reported lack of confidentiality by counselors resulting in mistrust by clients. This mistrust related to accidental disclosure of clients’ identifiable information 80 (88.9%) resulted in counselors’ fatigue to regain client’s confidence. Discussing reconnection of clients with communities to encourage full HIV healing process 76 (84.4%) report is often not accepted by client thus causing frustration for the counselor. These variables were however not statistically significant Fifty (55.6%) of respondents assert that bureaucratic bottle neck of government policies (e.g., late supply and/or non-availability of test kits are hard to explain to clients after HIV counseling has been carried out as reported in Policies in counseling activities [Table 6]. Clients monitor and follow through to the community resulted in participants’ fatigue with due to several factors. Hypothesis testing (Chi-square calculated = 31.223; df = 4; p < O. OOI) revealed a significant relationship between counselors’ fatigue and counseling activities. Seventy (77.2%) respondents assert that client’s inability to access antiretroviral (ARVs) promptly makes counselors helpless and crippled in what to do for the client. Fear of client’s stigmatization and discrimination in the immediate environment resulted in migration to centers where the clients’ identities were hidden reported by 75 (83.3%) increased HCT workload for the counselors thus requiring the necessity of increasing counselors in high target centers. These variables were statistically significant with fatigue (Chi-square calculated = 11.906, df = 6; P < 0.05).
|Variable||Fatigued F (%) Mean SD||Not fatigued F (%) Mean SD||Total (%)|
|(i) Disclosure of positive result is often difficult||50 (55.6)
|(ii) Discordant result disclosure is often difficult to handle||68 (75.6)||22 (24.4)||90 (100)|
|(iii) Lack of confidentiality among counselors results in mistrust by clients||70 (77.8)||20 (22.2)||90 (100)|
|(iv) Break-in confidentiality related to accidental disclosure of clients’ identifiable information||80 (88.9)||10 (11.1)||90 (100)|
|(v) Connecting HIV clients with community social resources for HIV prevention, treatment, and care is often stressful||76 (84.4)||14 (15.6)||90 (100)|
|Variable||Fatigued F (%) Mean SD||Not fatigued F (%) Mean SD||Total (%)|
|(i) Bureaucratic bottleneck of government policies (e.g., availability or none availability of test kits) is hard to explain to clients||50 (55.6)
|(ii) Clients’ inability to access antiretrovirals promptly makes counselors helpless and crippled in what to do||65 (72.2)||25 (27.8)||90 (100)|
|(iii) Fear of client’s stigmatization and discrimination in the immediate environment||70 (77.8)||20 (22.2)||90 (100)|
|(iv) High client volume compared with the available number of counselors results in fatigue||75 (83.3)||15 (16.7)||90 (100)|
Burnout responses among counselors [Table 7] showed statistical significance (Chi-square calculated = 144.000; df = 7; P < 0.001) as 85 (94.4%) counselors felt run down and drained off physically or emotionally during or after work, 83 (92.2%) reported that high client volume increased workload and reduced counselors’ expected achievement rate, 81 (90%) felt frustrated when testing kits were not available or enough after counseling to perform a test. Disclosure of discordant result 80 (88.9%) was reported to be very difficult especially if the client is a woman, poor time management due to work overload, 78 (86.7%) caused fatigue, and 76 (84.4%) reported getting irritated by small problems within the work environment while 68 (75.6%) stated that organizational policies or bureaucracy frustrated their ability to do a good job.
|Variable||Fatigued F (%) Mean SD||Not fatigued F (%) Mean SD||Total (%)|
|(i) Counselors feel run down and drained off physically or emotionally during or after work||85 (94.4)||5 (5.6)||90 (100)|
|78.88 5.19||11.13 5.19|
|(ii) High client volume increased workload and reduced counselors’ expected achievement rate||83 (92.2)||7 (7.8)||90 (100)|
|(iii) Counselors feel frustrated when testing kits are not available or enough||81 (90)||9 (10)||90 (100)|
|(iv) Disclosure of discordant results can be very difficult, especially if the woman is positive?||80 (88.9)||10 (11.1)||90 (100)|
|(v) Poor time management due to work overload results in fatigue||78 (86.7)||12 (13.3)||90 (100)|
|(vi) Counselors get irritated by small problems within the work environment?||76 (84.4)||14 (15.6)||90 (100)|
|(vii) Counselors feel that organizational policies or bureaucracy frustrate their ability to do a good job||68 (75.6)||22 (24.4)||90 (100)|
The counseling fatigue subscale scores for counselors are reported in Tables 2–7. Mean scores for all subscales tended toward the high end, ranging from a mean of 72.50 (SD = 6.124) for accessibility of clients for HCT to a mean of 78.88 (SD = 5.19) for burnout responses among counselors.
Pearson correlation (r) analysis was done to determine the association between age and years of experience of respondents with explain and facilitate counseling activities. Descriptive statistics of age with explain and facilitate counseling activities revealed mean age = 2.40, SD = 0.726 while explain and facilitate counseling activities mean value = 12.80 and SD = 7.726 with F (n) =90. The analysis showed a significant correlation (r) =0.610, P = 0.000 at 0.05 level (two-tailed) of age with explain and facilitate counseling activities, as shown in Table 8. Table 9 shows descriptive statistics to explain and facilitate counseling activities and years of experience of respondents. Explain and facilitate counseling activities mean = 12.80, SD = 7.726 and F (n) =90 while years of experience mean = 2.28, SD = 0.734, f (n) =90. Pearson correlation analysis result was significant (Pearson correlation (r) =0.695, P = 0.000 at the 0.05 level (two-tailed). This analysis revealed that age and years of experience of respondents were significantly associated with fatigue- provoking situations and the tasks performed.
|Descriptive statistics of age with explain and facilitate counseling activities||Mean||Standard deviation||Frequency (n)||Explain and facilitate||Sign P=0.05|
|Age (Pearson correlation, r) Explain and facilitate||2.40||0.747||90||0.610 **||0.000|
|Descriptive statistics of explain and facilitate with years of experience||Mean||Standard deviation||Frequency (n)||Years of Experience||Sign P=0.05|
|Explain and facilitate (Pearson correlation, r) Years of experience||12.80||7.726||90||0.695 **||0.000|
HCT is a key component in helping individuals to learn their HIV status and receive personalized risk-reduction counseling to help produce and prevent the acquisition or further transmission of the HIV. While studies have linked HCT activities to fatigue[23,13] the specific counseling activities that contribute to cause fatigue among HCT counselors are not yet assessed in Calabar. This study assessed perceived HCT counseling fatigue among counselors in Calabar using a total of 90 respondents from heart-to-heart centers.
Among the five subscale HCT counseling activities assessed, accessibility of clients for HCT, monitor and follow through activities and policies in counseling activities appeared to be most closely linked to counselors’ fatigue. The findings that counselors fatigue is most closely linked to accessibility, monitor, and follow through, and policies are not unexpected since the counselors need to probe into private personal life activities that often are difficult to discuss, see clients suffering and deal with multiple and serial losses on a daily basis Meremo, et al. Mbetu-Nzvenga et al. opined that counseling is a face to face communication where a counselor helps a client to identify, clarify and resolve a problem to make an informed decision. HIV/AIDS counseling involves confidential dialogue between a client and a health worker aimed at enabling client to evaluate the personal risk of HIV transmission, progression, and individual status to make decisions related to HIV and AIDS treatment where necessary.[3,1,5] Qiao et al. assert that HIV is a biomedical disease that has a social phenomenon requiring a positive social relationship that encourages honest and sincere discussions between the counselor and the client to help the client make an informed decision as seen in explain and facilitate counseling activities [Table 3]. These activities were statistically significant (Chi-square = 161.419, df = 5; P < 0.001) and correlated with socio-demographic data of age and years of experience revealing the presence of fatigue among the counseling. Monitor and follow through activities (Chi- square calculated = 31.223; df = 4; p < O. OOI) led to fatigue as identifying client’s location in the community for HCT services, bad roads, carrying bags, and boxes with testing supplies, providing private and confidential services, answer clients’ questions clearly to prevent labeling, stigmatization, and discrimination was often stressful.[2,8] Policies in counseling activities such as bureaucratic bottleneck of government policies (e.g., availability or none availability of test kits), clients’ inability to ARVs promptly, fear of client’s stigmatization, and discrimination in the immediate environment, and counseling of large number of clients made counselors helpless and crippled in what to do. These activities were found to be statistically significant (Chi-square calculated = 11.906; df = 6; P < 0.05) with fatigue as reported in other studies.[6,8] Occupational burnout was prevalent among HCT counselors in this study area as reported in other studies.[11,12,14,18,19,20,23] Significant predictors for occupational burnout were age, years of experience, and number of counseling sections. In this study, the number of counselors compared with the workload resulted in long waiting time for clients[12,21] The available counselors were often exposed to more workload and other stressful conditions of providing required services to the clients, thus putting them at risk for burnout. Furthermore, patients may suffer in this process, as both occupational burnout and low staffing levels have been associated with a decline in quality of care.[21,25] Measuring the effect of health-care provider burnout on patient outcomes is an important area for future research, with powerful implications for maintaining HIV care and treatment programs. Burnout responses among counselors [Table 7] (Chi-square calculated = 144.000; df = 7; p <0.001) indicate fatigue as revealed in other studies.[15,1] The observed fatigue can be attributed to nature of illness, the multifaceted needs of client, low counseling resource personnel, ethical and psychosocial issues connected with HIV/AIDS, poor counseling time management, work environment policies, age, and years of experience.[15,16] Counseling activities thus have a direct and indirect impact on the counselors’ works related performance.[4,24,25,9] Findings from this study showed that HCT counseling fatigue varied among counselors’ socio-demographic data (age, and years of experience) with significant correlation with explain and facilitate counseling activities.
Fatigue in this study, as reported in other studies[11,26] affect care delivery outcome. Considering the adverse outcomes of fatigue, Hsieh, et al., Kruse, et al. Mgbekem, et al., Hsieh et al. proposed the adoption of hardiness and persuasive communication approaches where counselors learn to be more creative and flexible in finding new and different ways such as allowing for “time out” activities and holding staff retreats (with enjoyable activities to alleviate fatigue-related problems). The study showed that HCT fatigue has a significant correlation between age and years of experience with explain and facilitate counseling activities being significant predictors of HCT fatigue. Measuring the effect of HCT counselors fatigue on HIV care services outcomes is an important area for future research, with powerful implications for maintaining HIV care and treatment programs.
Declaration of patient consent
Patient’s consent not required as patients identity is not disclosed or compromised.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
- Persuasive communication skills in the uptake of HIV counseling and testing among female Nigerian university students: Focus on the University of Calabar. Mary Slessor J Med. 2013;12:46-59.
- [Google Scholar]
- Culture, Behaviour and AIDS in Africa. In: African Responses to HIV/AIDS between Speech and Action. KwaZulu Natal: University of KwaZulu Natal; 2012.
- [Google Scholar]
- Gender differences in burnout among HIV/AIDS counselors in North India. Public Policy Adm Res. 2011;1:1-8. Available from: https://www.researchgate.net/publication/266350990_gender_differences_in_burnout_among_hivaids_counselors_in_north_india
- [Google Scholar]
- Reasons for non-utilization of HIV/ AIDS screening services by women in Akwa Ibom state, Nigeria. Hamdard Med. 2007;50:100-8.
- [Google Scholar]
- The relationship between hardiness, coping strategies and burnout in psychiatric nurses. Hu Li Za Zhi. 2004;51:24-33.
- [Google Scholar]
- Maslach Burnout Inventory Manual (3rd ed). CA, USA: Palo Alto, Consulting Psychologists Press; 1996.
- Stress Appraisal and Coping. New York: Springer; 1984.