Factors Influencing Utilization of Voluntary Counseling and Testing Service in Kasenyi Fishing Community in Uganda

Factors Influencing Utilization of Voluntary Counseling and Testing Service in Kasenyi Fishing Community in Uganda Emmanuel Mugisha, PhD Gisela Hildegard van Rensburg, PhD Eugine Potgieter, PhD This article reports on part of a study that described models of voluntary counseling and testing (VCT) service delivery and analyzed how a model influenced uptake of VCT services in a Ugandan community. A quantitative, exploratory, and descriptive design was used. Respondents (N 5 127, 52% male, 48% female) provided data during structured interviews. Although knowledge about HIV transmission and prevention was high, only 47.2% of respondents had been tested for HIV. Married people were less likely to have been tested than unmarried people. The most common reasons for testing included risky lifestyle, signs and symptoms related to HIV, sex partners’ risky lifestyles, and a sex partner’s death. The most common barriers to testing were fear of results, belief that it was not necessary, and lack of time. VCT use was low. Sensitization to testing, mobilization of the community, and improving the quality and volume of VCT services are needed. (Journal of the Association of Nurses in AIDS Care, 21, 503-511) Copyright Ó 2010 Association of Nurses in AIDS Care Key words: HIV, Uganda, voluntary counseling and testing (VCT), VCT service delivery, VCT service utilization

HIV was detected in Uganda in as early as 1982 in Kashenshero, a small fishing village in Rakai District, which became the center of the epidemic in the

country, before spreading to the neighboring fishing villages and later to urban centers. In the 1990s, HIV prevalence rose to 18% before finally dropping to 6% in 2006 after behavioral change interventions (Ministry of Health [MoH] & ORC Macro, 2006). Despite gains made in reducing HIV prevalence, there is concern that the presence of HIV reservoirs in some fishing communities will erode the positive results (Ministry of Agriculture, Animal Husbandry, and Fisheries [MAAF], 2005). Subsequently, the Ugandan government and its development partners have made serious efforts to ensure that all Ugandans have access to voluntary counseling and testing (VCT) services (MoH, 2004). VCT is internationally recognized as an effective and important strategy for both HIV prevention and care (De Cock, Marum, & Mbori-Ngacha, 2003). Furthermore, VCT has been found to be a costeffective strategy for facilitating behavior change (Forsythe et al., 2002). VCT is, therefore, a core

Emmanuel Mugisha, PhD, is a country manager in the Program for Appropriate Technology in Health (PATH), Kampala, Uganda. Gisela Hildegard van Rensburg, PhD, is a senior lecturer in the Department of Health Studies, University of South Africa (UNISA) Pretoria, South Africa. Eugine Potgieter, PhD, is an associate professor for health sciences education in the Department of Health Studies, University of South Africa Pretoria, South Africa.

JOURNAL OF THE ASSOCIATION OF NURSES IN AIDS CARE, Vol. 21, No. 6, November/December 2010, 503-511 doi:10.1016/j.jana.2010.02.005 Copyright Ó 2010 Association of Nurses in AIDS Care

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intervention in the comprehensive strategy of the Ugandan government and its development partners to address HIV infection. Although VCT sites have been set up in almost all health units across the country, VCT use remains lower than projected (MoH, 2004). Seeley and Allison (2005) emphasized that poor VCT service utilization makes it harder to deliver other HIV-related care and treatment services because testing is the only way a person can know his/her HIV status.

Problem Statement Several measures have been put into place to curb the spread of HIV infection, including delivery of free or highly subsidized quality VCT services. Despite the usefulness of VCT services as an entry point to prevention for uninfected people, and for care, treatment, and support to those who test positive, the fishing communities in Uganda have not used this service as much as was expected (MAAF, 2005; MoH, 2004).

Aim and Objectives This article reports on Part 1 of a 3-part study whose overall aim was to explore and describe the current models of VCT service delivery in fishing communities on the shores of Lake Victoria, in Wakiso District, in Uganda. The objective of Part 1 was to describe factors that influence use of VCT services in Kasenyi fishing community.

Methodology The study took place in 2007 in Wakiso District, central Uganda, at Kasenyi fish landing site, located 25 kilometers from Kampala City. The study was quantitative, non-experimental, descriptive, and exploratory, and the study population consisted of residents of Kasenyi fish landing site, which has a population of approximately 1,500 adults (MAAF, 2005). Like other fishing communities in Uganda, Kasenyi is a dynamic center of activity, attracting a variety of people – fulltime fishermen, traders,

and fish processors, as well as commercial sex workers (Sambrook & Tanzarn, 2003). According to Allison and Seeley (2004), this kind of population mix, coupled with low or no use of condoms and alcoholism, creates a fertile ground for HIV transmission. Kasenyi landing site is served by two major hospitals, Kisubi Missionary Hospital (about 4 kilometers from Kasenyi) and Entebbe Government Hospital (about 7 kilometers away). After obtaining the register of residents from the local council chairman (village head), the researcher grouped men and women separately. A fish bowl technique was used to randomize the sample. Numbers were assigned to each person, numbered papers were folded and placed in a bowl, and papers were then drawn from the bowl until the desired sample was obtained. Individuals who were less than 15 years old (based on the village register) at the time of the study were excluded from the sampling frame. A total of 127 respondents (66 men, 61 women) were selected. Face-to-face, structured interviews were used to collect data. According to the MAAF (2005), many people in fishing villages have not had access to education, and illiteracy levels are high. The datacollection instrument was a 69-item structured interview schedule, consisting of six sections: social demographics, knowledge and use of VCT services, HIV testing, VCT campaigns, VCT awareness, and suggestions for improving VCT services. The instrument was translated into three key local languages (Luganda, Runyakitara, and Lusoga), and back translation was done to ensure consistency. Being fluent in all three languages, the first author interviewed each respondent in her/his most preferred language, but all responses were recorded in English. All interviews took place in Kasenyi, mainly at private locations in the respondents’ workplaces. The interviewer took a positivist approach, maintaining a distance between himself as a research expert and the goings-on in the research settings. He also took the position of an interested outsider (Walsh, 2001). The data were entered into the Epi-data version 3.1 computer program and analyzed using the Statistical Package for Social Sciences (SPSS) version 12.0. Statistical calculations were done for both descriptive and inferential statistics (Babbie, 2008).

Mugisha et al. / VCT Service in Kasenyi Fishing Community

Pretesting of the Data-Collection Tool The interview schedule was constructed based on a literature review, was closely related to VCT service delivery and utilization (MoH & ORC Macro, 2006), and was pre-tested to determine (a) whether respondents would understand the questions and instructions, and (b) the relevance of the questions. A total of 10 individuals were randomly selected from Ggaba in Kampala, Uganda, a fish landing site close to the study site. The interview schedule was revised based on pilot information and input from VCT experts before embarking on full data collection. Ethical Considerations The following methods were used to ensure that the study met ethical standards: approval and permission to conduct the study, which was obtained from the University of South Africa and the Uganda National Council for Science and Technology; voluntary informed participation; participants’ well being; and anonymity, justice, and confidentiality (UNCST 2007). Although interviews were done at respondents’ workplaces, privacy was ensured by politely asking those who came close to leave.

Results Of the 127 respondents, 66 (52%) were men and 61 (48%) were women. The respondents’ ages ranged from 16 to 44 years (M 5 29.8, median 5 29); 85 (66.5%) were married; 25 (19.7%) were single; 13 (10.2%) were divorced; and 4 (3.1%) were widowed. A total of 84 respondents (66.2%) could read fluently and easily, 39 (30.7%) could read with difficulty, and 4 (3.1%) could not read at all. Most of the participants spoke Luganda (n 5 106, 83.5%), 8 (6.3%) spoke English (the official language in Uganda), 8 (6.3%) spoke Runyakitara, and 5 (3.9%) spoke Lusoga. Of the respondents, 71 (55.9%) were employed in fishing activities and 56 (44.1%) in support services. Analysis of occupation and gender indicated that of the 71 respondents who were in fishing activities, the majority (n 5 42, 63.6%) were men. In contrast, of the 56 respondents engaged in providing support

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services, more than half (n 5 32, 52%) were women. Men were significantly more likely than women to engage in fishing activities (p 5 .044). A majority of the respondents (n 5 65, 51.2%) had obtained secondary level education (13 years of school), 49 (38.6%) had obtained primary level education (7 years of school), 12 (9.4%) had obtained tertiary level education (2-5 years of school after secondary education), and 1 (0.8%) had had no education (Ministry of Education and Sports [MOE&S], 2007). The majority of the respondents (n 5 96, 75.6%) had lived at Kasenyi fish landing site for more than 3 years, 14 (11%) for 2 to 3 years, 9 (7.1%) for 1 to 2 years, and only 8 (6.3%) had lived there for less than a year. Married respondents were significantly more likely to have stayed at Kasenyi fish landing site for more than 3 years as compared with unmarried respondents (p 5 .0001). The length of stay was not necessarily dependant on an individual’s occupation (p 5 .262) or gender (p 5 .611).

Knowledge About HIV and VCT All respondents were able to name two ways in which HIV was transmitted as well as two prevention methods. HIV transmission methods mentioned included having unprotected sex with an infected partner (n 5 108, 85%), sharing sharp instruments with an infected person (n 5 10, 8.2%), using unsterilized needles (n 5 4, 3.3%), blood transfusions (n 5 3, 2.7%), and mother-to-child transmission (n 5 2, 0.8%). HIV prevention methods mentioned included consistent use of condoms (n 5 114, 89.7%), abstinence (n 5 8, 6.2%), being faithful to one partner (n 5 3, 2.3%), and others (n 5 2, 1.8%). Most of the respondents knew how to find out whether they had HIV infection. The majority (n 5 96, 75.6%) knew that they could find out through HIV testing; 30 (23.6%) mentioned that they could find out through signs and symptoms assumed to be related to HIV. The majority (n 5 113, 89%) knew where they could be tested for HIV. Of those 113 respondents, 53 (41.7%) named Entebbe hospital as a test site, 27 (21.3%) named Kisubi hospital, 23 (18.1%) named the Uganda Virus Research Institute, and 12 (9.4%) named the AIDS Information Centre. These sites include government hospitals, missionary

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hospitals, and a non-governmental organization. There was no mention of any private testing site.

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Ever tested for HIV

Respondents Ever Tested for HIV More than half of the respondents (n 5 67, 52.8%) had never been tested for HIV. Of the 60 respondents who had been tested, all had received their HIV test results and the majority (n 5 57, 95%) had received counseling during the testing session. Of the 57 respondents who had been counseled, 36 (63.3%) had received individual counseling, 18 (31.7%) received counseling as a couple, and 3 (5%) received counseling as part of a group. Male and female respondents were equally likely to have been tested for HIV (n 5 30, 45.5% men; n 5 30, 49.2% women). Of the 25 respondents who were single, 16 (64%) had been tested for HIV; of the 85 who were married, only 36 (42.4%) had been tested; and of the 13 who were divorced, 7 (53.8%) had been tested (Figure 1). The reasons for seeking VCT service were varied. Of the 60 respondents who had been tested, 12 (20%) had lived a risky lifestyle, 10 (16.7%) had experienced signs and symptoms assumed to be related to HIV, 9 (15%) cited their sex partners’ risky lifestyles, 8 (13.3%) noted the death of a sex partner, 5 (8.3%) tested during pregnancy, 12 (20%) had no specific reason for an HIV test, and 4 (6.7%) indicated other reasons. Reasons for seeking VCT varied across gender, with most men testing because they had experienced signs and symptoms possibly linked to HIV, had lived a risky lifestyle, or had a sex partner who had died. In contrast, most women tested because they were worried about their sex partners’ lifestyles (Figure 2). For the respondents who had been tested, 59 (98.3%) liked the explanation of VCT results given by the counselor, the information received, and the overall services. They also liked the counselors’ attitudes (n 5 58, 96.7%), the language used in counseling (n 5 57, 95%), the level of confidentiality (n 5 57, 95%), and the waiting area (n 5 54, 93.3%). The least-liked aspects of VCT included the distance to the site (n 5 37, 61.7%), the waiting time (n 5 18, 30%), and lack of courtesy from VCT site staff (n 5 48, 80%).

Percentage

70 60

No

50

Yes

40 30 20 10 0 Single

Married

Divorced

Widowed

Marital Status

Figure 1. HIV testing and marital status (n 5 60).

Figure 2. Reasons for having VCT across gender (n 5 60).

Respondents’ Lifestyles and Risks of HIV Infection The majority of respondents (n 5 104, 81.9%) did not think their lifestyles had put them at risk of HIV, whereas 21 (16.5%) thought their lifestyles could have lead to their being infected with HIV, and 2 (1.6%) were not sure. In contrast, 60 respondents (n 5 41, 68.3%) indicated that receiving VCT services had caused them to change their behaviors to avoid

Mugisha et al. / VCT Service in Kasenyi Fishing Community

HIV infection. Women were 2 times more likely than men to change their behaviors after VCT service (p 5 .016). However, no significant differences in reported changes were found in terms of age group, marital status, educational level, or religion. Respondents’ Reasons for Not Testing for HIV A total of 67 (52.8%) respondents had never been tested for HIV. The most common reasons given for not testing were fear of the test results, no time for an HIV test, did not consider HIV testing necessary, and the expense (Figure 3). Attitudes, Perceptions, and Their Influence on VCT Use The 127 respondents were asked how they felt about accessing VCT services. Of them, 124 (97.6%) said that having VCT was a good idea and 3 (2.4%) said it was a bad idea. Of the 124 respondents who said VCT was good, 84 (67.7%) said it helped a person plan for the future and 40 (32.3%) said it was the only way people could know their HIV status. Of the 3 respondents who considered testing a bad thing, 2 Gender

60

Men Women

50

Percentage

40

30

20

507

(66.6%) stated that individuals died faster if they tested and found they had HIV, and 1 (33.4%) indicated that individuals could spread HIV if they knew their HIV status. More than half of the respondents (n 5 69, 54.3%) felt they might be supported if their friends knew they had had an HIV test, but 25 (19.7%) felt that they could be rebuked, and 33 (26%) could not tell. More women (n 5 14, 56%) than men (n 5 11, 44%) indicated they would be rebuked if their friends knew they had an HIV test (p 5 .048). Despite this, 114 (89.8%) of the respondents said they would find it easy to get tested for HIV, whereas 19 (7.1%) would find it difficult, and 4 (3.1%) could not tell. Among the respondents, 104 (81.9%) had discussed HIV-related issues with a sex partner, 81 (63.8%) had discussed HIV with a friend, 45 (35.4%) had discussed HIV with a relative, and 11 (8.7%) had discussed HIV with a religious leader. Only 13 (10.2%) had discussed HIV with a health worker. An overwhelming majority of the respondents (n 5 120, 94.5%) were willing to encourage a friend or a relative to go for HIV testing because testing allowed an individual to know his/her HIV status. Among the 7 respondents who would not encourage HIV testing, the reasons were that people would die faster if they knew they were infected with HIV (n 5 6, 83.3%) and that people would intentionally spread HIV if they knew they were infected (n 5 1, 16.7%). In general, respondents were not willing to pay for VCT; 89 (70.1%) said they would not pay for VCT. Of those who were willing to pay, 18 (64.4%) would pay less than 5,000 Ugandan shillings (U.S. $3.00), 4 (14.2%) would pay 5,000 to 10,000 Ugandan shillings, and 1 (3.6%) was willing to pay more than 10,000 Ugandan shillings. Willingness to pay did not differ by gender, age, or occupation.

10

Preferred Site for VCT Services 0 Expensive

Fear of results

No time to Not test necessary

Others

Reasons for having never had an HIV test

Figure 3. Reasons for never having had an HIV test.

The majority of respondents who had been tested indicated that they had last been tested for HIV at a health facility (n 5 49; 81.7%), 9 (15%) had last been tested at work, 1 (0.8%) had been tested at home, and another 1 (0.8%) had been tested at

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some other place. Reasons given for using a given VCT varied. Of the 49 respondents who had had an HIV test at a health facility, half of them (n 5 25, 51%) said they trusted the results from a health facility, 19 (31.7%) said a health facility was convenient, and 3 (5%) had no reason. If they were to test in the near future, half (n 5 64, 50.4%) indicated they would prefer a health facility, 55 (43.3%) would prefer their workplace, and only 3 (2.4%) would prefer home testing. VCT Awareness Campaigns Access to reading materials such as newspapers was limited. Only 9 (7.1%) of the respondents read printed material on a daily basis, whereas 36 (28.3%) read at least once a week, 50 (39.4%) read at least once a month, but 32 (25.2%) did not read printed material at all. In contrast, most respondents (n 5 106, 83.5%) listened to a radio on a daily basis, 16 (12.6%) listened at least once a week, 4 (3.1%) listened at least once a month, and 1 (0.8%) did not listen to a radio at all. Only 23 (18.1%) of the respondents watched television everyday, 40 (31.5%) watched at least once a week, 47 (37%) watched at least once a month, and 17 (13.4%) did not watch television at all. In the previous 3 months, the majority of the respondents (n 5 75, 60%) said they had not heard or read any messages about VCT service, whereas 47 (38.6 %) had, and 5 (1.4%) could not recall. Respondents who had heard a message about VCT were asked what messages they had heard; these included a call to go for VCT, the need for testing early and knowing ones’ HIV status, and the need to get more up-to-date information on HIV prevention, care, and treatment.

Discussion Participants in this study had high levels of knowledge about HIV transmission and prevention. The knowledge base on HIV transmission was consistent with findings from the recent Uganda sero-behavioral survey, where 98% of respondents were able to name at least two methods of HIV transmission (MoH & ORC Macro, 2006). It was not surprising that

a majority of the respondents mentioned condom use for prevention. Beyrer (2007) found that male condom use was a highly regarded method to prevent transmission of HIV and other sexually transmitted infections. In the study reported here, more men than women felt that their lifestyles had put them at risk of acquiring HIV (p 5 .017). In addition, women felt they were put at risk by their sex partners’ lifestyles. In other studies, more women than men thought they were at risk of acquiring HIV (De Paoli, Manongi, & Klepp, 2004; Maman, Mbwambo, Hogan, Kilonzo, & Sweat, 2001). It appears that the respondents in this study did not realize their risk, given that HIV prevalence in some fishing communities has been found to be as high as 24% (Kipp, Kabagambe, & Konde-Lule, 2002). Not acknowledging the risk for HIV in a population with high HIV prevalence rates could be a coping strategy (Vermund & Wilson, 2002). Despite high levels of knowledge about HIV transmission and prevention, only 60 (47.2%) respondents had ever tested for HIV. Male and female respondents were equally likely to have been tested for HIV (45.5% of men; 49.2% of women). Fako (2006) found a significant relationship between gender and willingness to test for HIV infection among students in Botswana (p 5 .001), where girls were more willing to test for HIV infection (56.8%) than boys (47.6%). In the current study, however, no statistically significant differences were found in relation to having been tested for HIV across gender, as an equal proportion of women and men had been tested for HIV. In the Uganda HIV/AIDS behavioral survey, 56.5% of men and 63.8% of women accessed HIV testing (MoH & ORC Macro, 2006). As in the current study, Corbett et al. (2006) found that being single was more often associated with getting tested for HIV. Reasons for seeking VCT service were varied and similar to reasons found in previous studies. Downing et al. (2001), Maman et al. (2001), and Sato et al. (2005) described a range of factors associated with HIV testing, with the most common being actual and perceived risks of and knowledge about HIV. Other reasons included planning for the future, worry, and curiosity. In their study, Bwambale, Ssali, Byaruhanga, Kalyango, and Karamagi (2008) reported that 94.9% of respondents considered VCT

Mugisha et al. / VCT Service in Kasenyi Fishing Community

important for the good of the individual and the family. The decision to have an HIV test may depend on anticipated benefits, especially if the individual expects a positive test. Previous studies showed that differences in attitudes toward testing depended on the community and medical resources available to an HIV-infected person. In more developed countries, fear of adverse consequences may be balanced by an awareness of the benefits of HIV-related medical assistance; the reverse may also be true in developing countries, where the lack of expected benefits from VCT may reinforce the decision not to seek or accept the test. Karamagi, Tumwine, Tylleskar, and Heggenhougen (2006) found that very few women agreed to HIV testing because of the fear of knowing that they had HIV, which would cause them to worry and die. Fear of test results was the major barrier to accessing VCT services in the current study. According to studies by Downing et al. (2001), Maman et al, (2001), and Nsabagasani and Yoder (2006), fears of a positive result were related to past sexual experiences and the consequences of the test result. Bwambale et al. (2008) reported that some men worried about taking an HIV test because to them, having a positive result meant imminent death. According to the MoH and ORC Macro (2006), reasons for not testing for HIV in Uganda mainly included the following: do not need the test (38.4%), do not know where to get a test (20.8%), the high cost of the test (15.4%), not knowing about HIV testing (12.8%), and fear of knowing the results (12.6%). In contrast, Wringe et al. (2008) found that the perceived risk of HIV motivated both men and women to undergo VCT. A majority of the respondents in this study had been tested at a health facility. Likewise, respondents said they would prefer future HIV testing to be done at a health facility, which could be related to the need to access a wide range of services, especially if the HIV test was positive. According to Vermund and Wilson (2002), expected benefits from VCT may reinforce the decision to seek or accept an HIV test. In the current study, home-based VCT was the least preferred site for HIV testing. Previous research has shown that home-based VCT offered challenges with regard to confidentiality and disclosure

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(Family Health International, 2005; Wolff et al., 2005). HIV discussions amongst community members are likely to have a positive influence on accessing and using VCT service. In this study, an overwhelming majority of those who had been tested (n 5 58, 96.7%) had discussed HIV-related issues with a sexual partner, a friend, a relative, a health worker, or a religious leader. Similarly, Gage and Ali (2005) found that men who had discussed HIV with their spouses were 1.6 times more likely to test than men who had not had such discussions. A study in Tanzania found that, for many participants, family, friends, and other community members played a significant role in recommending VCT services (Maman et al., 2001). Few respondents were willing to pay for VCT services, which was interesting because VCT service in Uganda was provided free of charge (MoH, 2004). This may mean that knowing that VCT services were free could increase testing. In their study in rural South Africa, Pronyk et al., (2002) attributed a 75% increase in clients presenting for voluntarily HIV testing, partly due to reductions in user fees. The radio plays a big role in the lives of rural communities and thus could be a good channel for delivering HIV messages. Researchers in Nigeria found that the radio had a huge potential to mobilize people against HIV, although they acknowledged a lack of capacity in many radio stations to provide quality coverage of HIV (Falobi, Olufemi-Kayode, Gold, & Frohardt, 2002).

Conclusion Despite the evidence that early HIV testing is an important entry into HIV prevention and treatment, only half of the respondents in this study (n 5 60, 52.8%) had accessed VCT service. Even with high levels of awareness about HIV transmission and prevention methods, there was limited awareness about the value of VCT in prevention and care. An encounter with VCT is likely to create a positive image about the services. Almost all of the respondents who had used VCT were happy to have accessed the services and were satisfied with the overall basic elements of VCT service. Factors likely

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to lead a person to test included discussing issues related to HIV with someone, acknowledging HIV risk, and knowing the benefits of testing. The major barrier to HIV testing was fear of the test results. Other barriers to testing included having no time for VCT, VCT was considered not necessary, VCT was seen as expensive, fear of being rebuked by friends, and the time spent at the health facility. Although stigma existed, it was not found to be a barrier to testing. There was a limited awareness about VCT service, its importance, and where it was available. Radio programs could help to raise awareness and mobilize people into VCT services, given that most of the respondents routinely listened to the radio.

Limitations and Recommendations This study was limited to VCT service use in one fishing community in Uganda. It did not include other communities where characteristics related to VCT delivery and use might have differed. Despite these limitations, two recommendations can be made to increase access, availability, and use of VCT service. First, there is a need to increase awareness of VCT services by mobilizing communities. Communities should be involved in VCT planning and implementation processes. If VCT service is taken as a norm in communities, community involvement and participation in VCT services will evolve, which could reduce fear of HIV testing and increase uptake of services. Second, there is need to progressively monitor VCT service delivery at health units through data collection and self-evaluation, using basic statistics about VCT services delivery. These periodic assessments could, for example, involve VCT counselors and short client-exit interviews. Most of the health personnel who offer VCT service are nurses, and the information in this article is most applicable to the nursing profession. This research provides information on factors affecting VCT service use at hospitals and insights into how service delivery could be improved. The results of this study provide evidence on low use of VCT services, and the need for sensitization, mobilization, and progressive monitoring of VCT and related

hospital services. Nurses are in a good position to initiate needed changes to improve service delivery.

Clinical Considerations

 Nurses involved in VCT in Uganda might consider using radio programs to promote the important services they offer and to raise awareness about VCT services.  It is important to tailor VCT messages to the client’s background, level of education, lifestyle, and expectations.  Nurses should encourage HIV testing for pregnant women and enroll those found to have HIV into Prevention of Mother to Child programs.  Nurses need to help collect key data about service delivery to use when planning to improve service delivery.

Disclosures The authors report no real or perceived vested interests that relate to this article (including relationships with pharmaceutical companies, biomedical device manufacturers, grantors, or other entities whose products or services are related to topics covered in this manuscript) that could be construed as a conflict of interest.

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