|Year : 2018 | Volume
| Issue : 4 | Page : 147-152
Strategies for improving the integrated program of HIV/AIDS with sexual and reproductive health: using nominal group technique
Maryam Hajizadevalokolaee1, Zohreh Shahhosseini2, Soghra Khani2, Fereshteh Yazdani3, Zeinab Hamzehgardeshi2
1 Student Research Committee, Mazandaran University of Medical Sciences, Sari, Iran
2 Sexual and Reproductive Health Research Center, Mazandaran University of Medical Sciences, Sari, Iran
3 Student Research Committee, Mazandaran University of Medical Sciences, Sari; PhD Candidate, Shahid Beheshti University of Medical Sciences, Tehran, Iran
|Date of Submission||22-Oct-2018|
|Date of Acceptance||20-Nov-2018|
|Date of Web Publication||15-Jan-2019|
Dr. Zeinab Hamzehgardeshi
Sexual and Reproductive Health Research Center, Mazandaran University of Medical Sciences, Sari; Department of Reproductive Health and Midwifery, School of Nursing and Midwifery, Mazandaran University of Medical Sciences, Sari; Traditional and Complementary Medicine Research Center, Mazandaran University of Medical Sciences, Sari
Source of Support: None, Conflict of Interest: None
Context: The spread of HIV is growing, so that its way of transmission has created worries in the field of sexual and reproductive health, because the wave of transmission has changed from injection to sexual activities.
Aims: To evaluate the perspectives of sexual and reproductive health experts and providers on strategies for improving the integrated program of HIV/AIDS with sexual and reproductive health using the nominal group technique (NGT).
Setting and Design: Mazandaran University of Medical Sciences, Sari, Iran. NGT.
Materials and Methods: It was a semiquantitative/qualitative methodology research through NGT, based on the opinions of 30 experts and sexual and reproductive health providers in the field of health in Mazandaran (2016).
Statistical Analysis Used: Semiquantitative/qualitative analysis.
Results: In total, 15 cases got the scores of 2–62 as strategies to improve the integrated program of HIV/AIDS with sexual and reproductive health. The highest scores were found in society-centered level and stigma management, and the lowest scores were found in individual-centered level and negotiation skill training.
Conclusion: One of the strategies to improve the integrated program of HIV/AIDS was the empowerment of women and men in sexual and reproductive health and stigma management. Based on the results, the NGT is a useful tool for doing researches and prioritizing the programs. Based on the expert opinion, it can be concluded that designing strategies based on individual-, community-, and society-centered approach would be an appropriate approach for improving the integrated program of HIV/AIDS with sexual and reproductive health issues in Iranian society.
Keywords: HIV/AIDS, Integration, Nominal group technique, Reproductive health, Sexual health
|How to cite this article:|
Hajizadevalokolaee M, Shahhosseini Z, Khani S, Yazdani F, Hamzehgardeshi Z. Strategies for improving the integrated program of HIV/AIDS with sexual and reproductive health: using nominal group technique. J Nurs Midwifery Sci 2018;5:147-52
|How to cite this URL:|
Hajizadevalokolaee M, Shahhosseini Z, Khani S, Yazdani F, Hamzehgardeshi Z. Strategies for improving the integrated program of HIV/AIDS with sexual and reproductive health: using nominal group technique. J Nurs Midwifery Sci [serial online] 2018 [cited 2020 May 27];5:147-52. Available from: http://www.jnmsjournal.org/text.asp?2018/5/4/147/250207
| Introduction|| |
According to the report from the Joint United Nations Programme on HIV/AIDS, around 34 million people live with HIV, 16.8% of whom are women and 3.4% are children aged below 15 years. Although the spread of HIV in the Iranian general public is <1%, the growing spread of diseases transmitted through sex and the change of HIV transmission wave from infected syringes to infected heterosexual women has created concerns for the programmers of the prevention of these diseases.,,
One of the primary steps in many countries is taking care of needs for people's sexual and reproductive health, because the number of sexually transmitted infections is growing and having access to it is everyone's right in the field of health., In 1994, governments announced global access to pregnancy health services equal with the decrease of the disease and emphasized it as a part of millennium development goals to 2015. The main components of care in the field sexual and reproductive health are improving prenatal and postnatal programs, offering quality services for family management and infertility services, eliminating unsafe abortions, preventing and curing sexually transmitted diseases such as HIV and cervical cancer, and improving healthy sexual relationship and violence against women and gender-based violence.,
One of the global programs to eradicate HIV is having strategies such as the linkage of sexual and reproductive services with HIV/AIDS and the integration of HIV/AIDS with sexual and reproductive health,, where the integration of HIV/AIDS program is considered a tool to improve the preventive health-care (PHC) system. The goal of this approach is to integrate PHC empowerment system to do more tests on HIV patients, to do faster and more efficient antiretroviral therapy, and to have more extensive care for HIV-positive patients. The integration of sexual and reproductive health services with HIV services potentially brings some advantages which are improved effectiveness, more extensive care coverage, and cost-effective services. Moreover, offering services in one package or for one person will be possible, which will improve the reception of services in a region, laboratory services, care quality, and patients' satisfaction and will alleviate stigma in people infected by HIV. Linkage is the connection between health and service centers in hospitals, so that the bilateral cooperation of centers in policy, programs, and services of SRH and HIV is defined., A study in 2011 dealt with the prioritization of cases for informing about sexual health program of the youth. One study stated the challenges and opportunities of the program of HIV and sexual health and helping people according to the opinions of key persons in country. This study was done in South Africa and used the nominal group technique (NGT). One of the studies to have prioritized strategies through NGT was conducted in Iran, which prioritized strategies to improve teenagers' physical activities through NGT, and there is not a study to have dealt with strategies for improving the program of HIV/AIDS with sexual and reproductive health through NGT.
Because, in most cases, it is important for health policy makers to obtain the viewpoints of experts in the field of health in a scientific process, it will be useful to use group-based research techniques in that matter. For example, group discussions with open questions, Delphi method, and NGT are group based. NGT has been included in the study, because unlike Delphi method and group discussion, it allows all the participants to express their opinions, does not let the opinions of small group takeover, and the viewpoints of all experts are used in a short time. Therefore, this study tries to present strategies for integrating the HIV/AIDS program with sexual and reproductive health through the viewpoints of experts in the field of sexual and reproductive health.
| Materials and Methods|| |
This study's research proposal was approved by the Student Research Committee affiliated with Mazandaran University of Medical Sciences, Sari, Iran (IR.MAZUMS.30-94).
The research was done through semiquantitative/qualitative methodology, using NGT based on the opinions of 30 experts in the field of health in Mazandaran, Iran (2016) to prioritize strategies for improving the integrated program of HIV/AIDS with sexual and reproductive health. The reasons for using this method are adding to the sessions' productively, having the members' participation, and keeping balance in the amount of this participation and creative solving of the issue. Because this method is democratic, no one has an overriding opinion. Furthermore, viewpoints are prioritized and group decision-making is facilitated.
The participants of the session were five experts in sexual and reproductive health and fifteen experts in the field of midwifery and sexual and reproductive health, and ten experts in counseling in midwifery field. The participants were chosen and invited based on their extensive information and experience in the field of sexual and reproductive health. To ensure the validity of the findings in this study, we considered the heterogeneity of the participants in terms of educational background and work experience. The meeting was held in the Department of Reproductive Health and Midwifery Counseling in Mazandaran University of Medical Sciences. Preparation for the meeting of the nominal group was done a week before the meeting. The meeting participants from the group of experts were invited through e-mail, social networks, and face to face. The required tools for the meeting were pens and paper for each member, a flip chart, makers, and a U-desk, which were prepared. In this study, the phases of the NGT were implemented.
Opening the session and introduction
Welcoming warmly, the facilitator explained each person's role, goals of the session and their importance, and the importance of everybody's participation in activities and the process of NGT to all the participants of the session. The researcher presented a review on the best existing evidence of the integrated program of HIV/AIDS with the program the mother–child health and family management, and named texts about the integrated program in the world for the people. It should be mentioned that, in this phase, the facilitator explained the rules of the nominal group's session for the members (5 min).
Silent generation of ideas in the writing
Members answered the main question of the research in silence in 5–10 min: Based on the presented results and findings and your own rich experiences, what strategies do you propose to improve the integrated program of HIV/AIDS with sexual and reproductive health. In this phase, the members were asked to write their ideas down in silence.
Round-robin recording of ideas
In this phase, the participants expressed their opinions without any discussion and the facilitator recorded their opinions on the flip chart. In this phase, all members had equal time to express their opinions, so that every member expressed their opinions. This phase took 60 min.
Serial discussion on the ideas
In this phase, every idea were discussed and clarified in turn. The facilitator investigated the strategies written on the flip chart from the beginning of the list. Three issues were implemented in his phase.
- Repeated ideas were eliminated
- Ideas with similar concepts were integrated
- An idea was clarified by its presenter or other participating experts if it was not clear.
This session time is related to experts' discussion on the ideas. This phase took 40 min.
Voting to select the most important ideas
In this phase, the members were asked to list five important ideas from the remaining items of the last phase in their own opinions and number them from five to one based on their importance. After final voting, the facilitator added up the scores. Items with scores below two were removed from the final list. This phase took 10 min.
Discussion on the selected ideas
This phase is not an essential step for the NGT, but it is recommended. This phase helps the group make the ideas more coherent. This phase took 10 min.
| Results|| |
Sociodemographic characteristics of participants
The mean age of participants was 32.53 (standard deviation [SD] = 8.68) years. The mean work experience was 8.50 (SD: 7.60) years. Five experts were RM, PhD IN reproductive health. Fourteen health providers were RM. Ten health provides were RM and master candidate in midwifery counseling that had worked in public health center in Sari, Iran. One of the health providers was RN that worked in maternal health unit in health center, SARI, Iran.
In total, 30 multidiscipline experts participated in the session for 120 min. Answering the question “Based on the presented results and findings and your own rich experience, what strategies do you propose to improve the integrated program of HIV/AIDS with sexual and reproductive health. Participants presented a wide range of items. In the phase of generating and recording ideas, 54 items were presented by the session members. Then, in the phase of discussion, repeated items were removed, similar items were integrated, and, finally, the remaining items were categorized in the three levels of the individual centered (including infected individual), community centered (including schools and health environment), and society centered [Table 1].
|Table 1: Items presented by the members of the nominal group session about strategies for integrating HIV/AIDS program with sexual and reproductive health in the level of generating and recording ideas|
Click here to view
Then, in the phase of voting, items with scores below two were removed from the list. Finally, 15 items with scores from 2 to 62 were listed as presented strategies, which are discussable in the levels of individual-based strategies, community-based strategies, and society-based strategies. Most proposed strategies to integrate HIV/AIDS with sexual and reproductive health were based on community. However, culture making, stigma management, clarification, education, and advertisement by the media got the highest scores [Table 2].
|Table 2: Items presented by the members of the nominal group meeting about strategies for integrating HIV/AIDS program with sexual and reproductive health in the voting phase|
Click here to view
| Discussion|| |
Along with other studies, this study showed that one of the strategies to improve the integrated program of HIV/AIDS from the perspective of experts participating in the discussion is the empowerment of women and men in sexual and reproductive health. It has been shown that this single word evokes access to information, skill, services, technology, participation in decision-making and women's access to economic resources, and for sex workers who are exposed to social harms such as drugs, diseases, violence, discrimination, debt, crime, and sexual exploitation, the word “empowerment” will be a key strategy for harm-reduction of getting HIV diseases. Using condoms and negotiation is one of the skills for women's empowerment in the field of sexual and reproductive health of women with HIV. Because the HIV infection wave in Iran has shifted from infected syringes to sexual relationships, the role of negotiation skill has become more prominent.
In their study, Hosseinpoor et al. mentioned the gender roles in society, institutionalized discrimination, and society structure and said that women have a lower level of health than men and he equated health with the level of education, household economic status, jobs, and people's marital status. On the other hand, using centers for male health is important because many men do not show willingness to receive health services. Moreover, according to UNADIS report, for the health of men with HIV who kind of have sexual relationship with other men, no proper researches have been conducted.
According to the experts' opinions, another issue in the area of individuals is using peers and support groups for people at risk and risky people. Having peer groups with sick people, educating and supporting them can increase the knowledge of HIV, sharing equipment and related information, and using condoms.
Individual-centered level includes a support system which the person at risk and the inflicted person will encounter. In this level, this study agrees with the studies that mentioned the workers of the area of health are not efficient in education and counseling and do not have proper access to information and education packages and most infected people are not detectable; and along with it, one study has announced that at the level of giving services, some factors weaken the integration system such as heavy load of customer's referral, lack of staff and improper education and skills in SRH, resistance against change and inadequate monitoring systems about integration, and other study also knows more care coverage over people infected by HIV as one of the goals of system integration approach and announces detecting and screening of the infected people, one of the problems in this area.
According to the experts, one of the support factors in the community system is using school-based education techniques. Because a big deal of people's time is spent in society, organizational structure and its processes can have underlying impacts on people's health and behavior. These organizations such as schools and universities are actually considered a part of the social identity, which makes an opportunity for making social support for behavioral changes in people., By investigating different types of educational interferences in school, a systematic review study shows that having educational and counseling programs at schools has an impact on the knowledge, attitude, and the use of condoms by adolescents.
Society-centered level is about policy making and culture of the society. According to the experts, in this level, some factors have been mentioned such as establishing and using adolescent-friendly services using mass media, allocating huge budgets for people's sexual and reproductive health, using experienced people and consultants, increasing intersectional cooperation and stigma management.
The findings of this study say that the best form of services for adolescents is the adolescent-friendly services that give services to teenagers, especially the ones at high risk or without access to services, at right time and place and with good prices without considering the ethnicity and religion and with no discrimination. These services are efficient because they are provided by educated and motivated health-care providers who do not judge. Having the teenage-friendly service is effective for reducing risk and improving the integrated program. Although studies through mass media are low or medium quality, information through mass media has had a positive effect on people's knowledge of HIV transmission ways and their reducing the risky behaviors.
Finally, experts say that one of the most important strategies for improving integrated services is stigma management. As a cultural and social phenomenon related to the individual, community, and the environment, stigma is defined as social inequality phenomenon where some people are considered worthless and some are at high levels of power. There have been many interferences to manage stigma in countries, which had an immediate positive effect on people's attitude and behavior and their long-term effects have not been investigated.
On the other hand, because many HIV patients suffer from poverty along with physical problems, making NGOs, taking care of people's financial issues, reducing expenses and allocating proper budgets to give quality to the services are other strategies to improve the integrated program of HIV/AIDS with sexual and reproductive health, according to the experts' opinions. This all agrees with the study of Smith (2012), which is about allocating a little financial budgets for SRH systems. On the other hand, based on the experts' opinions, other society-centered strategies in this area are employing more staff due to the high volume of work, and consultants who have specialized in sexual and reproductive health, so that people's questions are answered correctly and people's problems are taken care of in an individual-centered manner. Lack of guidance policy in the integrated care, little financial budgets for SRH, and a weak reference system are some factors that put flaws in the integrated system.
In this study, for the first time, the specialist's ideas were discussed about strategy of improving the integrated program of HIV/AIDS with sexual and reproductive health improving in and mentioned that integration program would be accessed in socioecological factors. A qualitative study is very useful for the better understanding of findings.
| Conclusion|| |
The main finding of this study is the special viewpoint of the specialists to the role of individual and social factors in improving the integrated program of HIV/AIDS with sexual and reproductive health with using NGT. Therefore, it can be concluded that designing strategies based on individual-, community-, and society-centered approach would be an appropriate approach for improving integrated program of HIV/AIDS with sexual and reproductive health issues in Iranian society. Based on the results, it can be said that the method of NGT is a useful tool for doing researches and prioritizing the programs. Using this strategy in group sessions, the participants can come to an important conclusion for efficient programming through expressing their experiences and using the newest evidence and information sources.
All authors contributed to this research.
Financial support and sponsorship
This study was financially supported by Student Research Committee affiliated with Mazandaran University of Medical Sciences.
Hereby, we extend our gratitude to the Research Committee of Mazandaran University of Medical Sciences for the financial support of this study (IR.MAZUMS.95.S232). We would also like to thank Mrs. Maedeh rezaei for her cooperation as facilitator and all the participants for assisting us in this research project.
| References|| |
Lindegren ML, Kennedy CE, Bain-Brickley D, Azman H, Creanga AA, Butler LM, et al.
Integration of HIV/AIDS services with maternal, neonatal and child health, nutrition, and family planning services. Cochrane Database Syst Rev 2012;9:CD010119.
Farahani FK, Cleland J, Mehryar AH. Correlates and determinants of reproductive behavior among female university students in Tehran. J Reprod Infertil 2012;13:39-51.
Lotfi R, Ramezani Tehrani F, Yaghmaei F, Hajizadeh E. Barriers to condom use among women at risk of HIV/AIDS: A qualitative study from Iran. BMC Womens Health 2012;12:13.
Ramezani Tehrani F, Malek-Afzali H. Knowledge, attitudes and practices concerning HIV/AIDS among Iranian at-risk sub-populations. East Mediterr Health J 2008;14:142-56.
Cottingham J, Kismodi E, Hilber AM, Lincetto O, Stahlhofer M, Gruskin S, et al.
Using human rights for sexual and reproductive health: Improving legal and regulatory frameworks. Bull World Health Organ 2010;88:551-5.
Wight D, Fullerton D. A review of interventions with parents to promote the sexual health of their children. J Adolesc Health 2013;52:4-27.
Glasier A, Gülmezoglu AM, Schmid GP, Moreno CG, Van Look PF. Sexual and reproductive health: A matter of life and death. Lancet 2006;368:1595-607.
Temmerman M, Khosla R, Say L. Sexual and reproductive health and rights: A global development, health, and human rights priority. Lancet 2014;384:e30-1.
Kennedy CE, Spaulding AB, Brickley DB, Almers L, Mirjahangir J, Packel L, et al.
Linking sexual and reproductive health and HIV interventions: A systematic review. J Int AIDS Soc 2010;13:26.
Annang L, Hannon L 3rd
, Fletcher FE, Horn WS, Cornish D. Using nominal technique to inform a sexual health program for black youth. Am J Health Behav 2011;35:664-73.
Smit JA, Church K, Milford C, Harrison AD, Beksinska ME. Key informant perspectives on policy-and service-level challenges and opportunities for delivering integrated sexual and reproductive health and HIV care in South Africa. BMC Health Serv Res 2012;12:48.
Baheiraei A, Hamzehgardeshi Z, Mohammadi MR, Mohammadi E, Vedadhir A. Expert approaches to promote adolescent physical activity in iran: Development of the promoting strategies using the nominal group technique meeting. J Phys Act Health 2014;11:961-5.
Gupta GR. Gender, sexuality, and HIV/AIDS: The what, the why, and the how. Siecus Rep 2001;29:6-13.
Rekart ML. Sex-work harm reduction. Lancet 2005;366:2123-34.
Blanchard AK, Mohan HL, Shahmanesh M, Prakash R, Isac S, Ramesh BM, et al.
Community mobilization, empowerment and HIV prevention among female sex workers in South India. BMC Public Health 2013;13:234.
Haghdoost AA, Mostafavi E, Mirzazadeh A, Navadeh S, Feizzadeh A, Fahimfar N, et al.
Modelling of HIV/AIDS in Iran up to 2014. J AIDS HIV Res 2011;3:231-9.
Hosseinpoor AR, Stewart Williams J, Amin A, Araujo de Carvalho I, Beard J, Boerma T, et al.
Social determinants of self-reported health in women and men: Understanding the role of gender in population health. PLoS One 2012;7:e34799.
Smith JA, Braunack-Mayer A, Wittert G. What do we know about men's help-seeking and health service use? Med J Aust 2006;184:81-3.
Doroudi F. Islamic Republic of Iran AIDS Progress Report, On Monitoring of the United Nations General Assembly Special Session on HIV and AIDS; 2013.
Medley A, Kennedy C, O'Reilly K, Sweat M. Effectiveness of peer education interventions for HIV prevention in developing countries: A systematic review and meta-analysis. AIDS Educ Prev 2009;21:181-206.
Pfeiffer J, Montoya P, Baptista AJ, Karagianis M, Pugas Mde M, Micek M, et al.
Integration of HIV/AIDS services into African primary health care: Lessons learned for health system strengthening in mozambique-a case study. J Int AIDS Soc 2010;13:3.
McLeroy KR, Bibeau D, Steckler A, Glanz K. An ecological perspective on health promotion programs. Health Educ Q 1988;15:351-77.
Voisin DR, Hong JS, King K. Ecological factors associated with sexual risk behaviors among detained adolescents: A systematic review. Child Youth Serv Rev 2012;34:1983-91.
Paul-Ebhohimhen VA, Poobalan A, van Teijlingen ER. A systematic review of school-based sexual health interventions to prevent STI/HIV in Sub-Saharan Africa. BMC Public Health 2008;8:4.
Bertrand JT, O'Reilly K, Denison J, Anhang R, Sweat M. Systematic review of the effectiveness of mass communication programs to change HIV/AIDS-related behaviors in developing countries. Health Educ Res 2006;21:567-97.
Mahajan AP, Sayles JN, Patel VA, Remien RH, Sawires SR, Ortiz DJ, et al.
Stigma in the HIV/AIDS epidemic: A review of the literature and recommendations for the way forward. AIDS 2008;22 Suppl 2:S67-79.
Parker R, Aggleton P. HIV and AIDS-related stigma and discrimination: A conceptual framework and implications for action. Soc Sci Med 2003;57:13-24.
Brown L, Macintyre K, Trujillo L. Interventions to reduce HIV/AIDS stigma: What have we learned? AIDS Educ Prev 2003;15:49-69.
[Table 1], [Table 2]