Health and palliative care needs of key populations in Zimbabwe

Ensuring appropriate, accessible healthcare for key populations is increasingly recognised as a global health issue, particularly in lower and middle income countries where civil rights are the weakest. 

Background

Key populations suffer frequent human rights violations due to legal and social conditions, are socially marginalised, have significantly lower uptake of essential health services and are disproportionately affected by HIV and other epidemics compared to the general population[1].

Key populations are those who, due to behavioural, politico-socioeconomic and structural factors, face increased risk of sexually transmitted illnesses including HIV and some cancers[2].

They are also at significant risk for stroke, heart disease, poor mental health, psychological distress and depression[3][4].

Currently and particularly in Africa, little is known about the palliative care needs of key populations.

For the study, key populations included sex workers (people who exchange sexual services or favours for money or gifts) and sexual and gender minorities (lesbian, gay, bisexual, transgender, intersex individuals (LGBTI).

The research

The study took place during 2014/15 in four sites around Zimbabwe. A total of 60 key population participants contributed to focus group discussions.

The researcher conducted in-depth interviews with 12 representatives of support agencies, palliative care organisations, and private medical practitioners known to be familiar with key population issues, along with three focus group discussion participants who self-identified as living with life limiting illness.

Results

Three distinct themes emerged from the data:

1. Illnesses were caused by ‘bad behaviour’: key populations were perceived as having brought illnesses on themselves through their sexual behaviour and deserved blame not compassion. “This is a taboo, an abomination. What are you doing? No wonder you are in this situation” – Palliative care nurse.
2. Access to health and palliative care was conditional on conforming to sexual norms: key populations felt that they needed to pretend, deny or lie about their sexual identity/behaviour. “…they would ask where your partner is for them to do the tracking system… So I could not take my girlfriend to the clinic with me and I would take any man on the road to go with me so I could get treated.” – Lesbian focus group participant.
3. Health care and support from health workers was determined by personal attitude rather than professional ethics. “…in the first place I think to be lesbian or gay it’s a sin… I think it emanates from how I understand the Bible. My view comes biblically that it’s a sin.” – Palliative care nurse.

The study provided evidence of moral judgement, blame, inappropriate curiosity, discrimination and withholding treatment by health workers.

Care and treatment depended on remaining undercover, posing as heterosexual and hiding sex worker status for fear of legal and social repercussions.

The attitude of health workers determined care and was often based on ignorance of lifestyles and sexual practices, and characterised by inappropriate language.

There was little or no support from family and community. Most health care support was provided within sexual identity groups and least from health workers. Stories of painful, lonely and undignified deaths were common.

Lessons learned

A safe and confidential environment honouring human rights would facilitate disclosure and ensure effective appropriate treatments for key populations.

Educational programs are needed to reduce stigma and enhance sensitive interviewing skills, aiming to integrate a human rights approach to health and palliative care at all levels of practice.

Further research is required into attitudinal change programmes to inform policy change and ensure professional palliative care for all.

Conclusion

This research underscores the WHA resolution on palliative care (2014) that recognises the human right to palliative care.

More specifically it draws the attention of all African health and palliative care providers to Goal 3 of the Sustainable Development Goals: to ensure healthy lives and ensure well-being for all at all ages.

The evidence challenges African health care providers to recognise, respect and attend to the uniqueness of each patient AND the specific challenges of key populations.

References