title: A socio-ecological perspective of access to and acceptability of HIV/AIDS treatment and care services: a qualitative case study research.
abstract: BACKGROUND
  Access to healthcare is an essential element of health development and a fundamental human right. While access to and acceptability of healthcare are complex concepts that interact with different socio-ecological factors (individual, community, institutional and policy), it is not known how these factors affect HIV care. This study investigated the impact of socio-ecological factors on access to and acceptability of HIV/AIDS treatment and care services (HATCS) in Wolaita Zone of Ethiopia.
  
  
  METHODS
  Qualitative case study research was conducted in six woredas (districts). Focus group discussions (FGDs) were conducted with 68 participants in 11 groups (six with people using antiretroviral therapy (ART) and five with general community members). Key informant interviews (KIIs) were conducted with 28 people involved in HIV care, support services and health administration at different levels. Individual in-depth interviews (IDIs) were conducted with eight traditional healers and seven defaulters from (ART). NVIVO 10 was used to assist qualitative content data analysis.
  
  
  RESULTS
  A total of 111 people participated in the study, of which 51 (45.9%) were male and 60 (54.1%) were female, while 58 (53.3%) and 53 (47.7%) were urban and rural residents, respectively. The factors that affect access to and acceptability of HATCS were categorized in four socio-ecological units of analysis: client-based factors (awareness, experiences, expectations, income, employment, family, HIV disclosure and food availability); community-based factors (care and support, stigma and discrimination and traditional healing); health facility-based factors (interactions with care providers, availability of care, quality of care, distance, affordability, logistics availability, follow up and service administration); and policy and standards (healthcare financing, service standards, implementation manuals and policy documents).
  
  
  CONCLUSIONS
  A socio-ecological perspective provides a useful framework to investigate the interplay among multilevel and interactive factors that impact on access to and acceptability of HATCS such as clients, community, institution and policy. Planners, resource allocators and implementers could consider these factors during planning, implementation and evaluation of HATCS. Further study is required to confirm the findings.
authors.affiliation: School of Nursing & Public Health, Howard College, University of KwaZulu-Natal, King George V Ave, Durban, 4041, South Africa. berekbot@yahoo.com.|Health Economics and HIV/AIDS Research Division (HEARD), University of KwaZulu-Natal, Durban, South Africa. berekbot@yahoo.com.
authors.forename: Bereket
authors.initials: B
authors.lastname: Yakob
authors.affiliation: School of Nursing & Public Health, Howard College, University of KwaZulu-Natal, King George V Ave, Durban, 4041, South Africa. Ncamab@ukzn.ac.za.
authors.forename: Busisiwe Purity
authors.initials: BP
authors.lastname: Ncama
mesh_terms: D000163:Acquired Immunodeficiency Syndrome / Q000628:therapy; D000328:Adult; D003141:Communicable Diseases; D005002:Ethiopia; D005260:Female; D017144:Focus Groups; D015658:HIV Infections / Q000628:therapy*; D006291:Health Policy; D006296:Health Services; D006297:Health Services Accessibility; D006801:Humans; D008297:Male; D008875:Middle Aged; D010342:Patient Acceptance of Health Care; D036301:Qualitative Research; D011787:Quality of Health Care; D012111:Residence Characteristics; D012424:Rural Population; D012931:Social Environment; D057545:Social Stigma; D012959:Socioeconomic Factors; D014505:Urban Population