title: 'Deep down in their heart, they wish they could be given some incentives': a qualitative study on the changing roles and relations of care among home-based caregivers in Zambia.
abstract: BACKGROUND
  Across Sub-Saharan Africa, the roll-out of antiretroviral treatment (ART) has contributed to shifting HIV care towards the management of a chronic health condition. While the balance of professional and lay tasks in HIV caregiving has been significantly altered due to changing skills requirements and task-shifting initiatives, little attention has been given to the effects of these changes on health workers' motivation and existing care relations.
  
  
  METHODS
  This paper draws on a cross-sectional, qualitative study that explored changes in home-based care (HBC) in the light of widespread ART rollout in the Lusaka and Kabwe districts of Zambia. Methods included observation of HBC daily activities, key informant interviews with programme staff from three local HBC organisations (n = 17) and ART clinic staff (n = 8), as well as in-depth interviews with home-based caregivers (n = 48) and HBC clients (n = 31).
  
  
  RESULTS
  Since the roll-out of ART, home-based caregivers spend less time on hands-on physical care and support in the household, and are increasingly involved in specialised tasks supporting their clients' access and adherence to ART. Despite their pride in gaining technical care skills, caregivers lament their lack of formal recognition through training, remuneration or mobility within the health system. Care relations within homes have also been altered as caregivers' newly acquired functions of monitoring their clients while on ART are met with some ambivalence. Caregivers are under pressure to meet clients and their families' demands, although they are no longer able to provide material support formerly associated with donor funding for HBC.
  
  
  CONCLUSIONS
  As their responsibilities and working environments are rapidly evolving, caregivers' motivations are changing. It is essential to identify and address the growing tensions between an idealized rhetoric of altruistic volunteerism in home-based care, and the realities of lay worker deployment in HIV care interventions that not only shift tasks, but transform social and professional relations in ways that may profoundly influence caregivers' motivation and quality of care.
authors: Dignitas International, Research Department, Zomba, Malawi. f.cataldo@dignitasinternational.org.
authors: Fabian
authors: F
authors: Cataldo
authors: Institute for International Health and Development, Queen Margaret University, Edinburgh, Scotland. kkielmann@qmu.ac.uk.
authors: Karina
authors: K
authors: Kielmann
authors: Independent Consultant, New York, NY, USA. tkielmann@hotmail.com.
authors: Tara
authors: T
authors: Kielmann
authors: International HIV/AIDS Alliance, Brighton, UK. gmburu@aidsalliance.org.|Division of Health Research, Lancaster University, Lancaster, UK. gmburu@aidsalliance.org.
authors: Gitau
authors: G
authors: Mburu
authors: Zambia AIDS Related Tuberculosis Project, University of Zambia, Lusaka, Zambia. mushekem@yahoo.com.
authors: Maurice
authors: M
authors: Musheke
mesh_terms: D000328:Adult; D044966:Anti-Retroviral Agents / Q000627:therapeutic use*; D001291:Attitude of Health Personnel; D017028:Caregivers / Q000523:psychology*; D003430:Cross-Sectional Studies; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000451:nursing*; D006282:Health Personnel / Q000523:psychology*; D006699:Home Care Services / Q000458:organization & administration*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009042:Motivation; D024382:Professional Role / Q000523:psychology*; D036301:Qualitative Research; D015024:Zambia
chemical_list: D044966:Anti-Retroviral Agents
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