Introduction

Following initial reported instances of HIV/AIDS in the 1980s, the disease became a worldwide pandemic. The United Nations and affiliated international organizations have since initiated firm and extensive actions to battle HIV/AIDS, and there has been progress in terms of a significant expansion of access to antiretroviral therapy and subsequent fewer HIV-related deaths (United Nations AIDS 2014). However, countries in Sub-Saharan Africa have experienced the worst of the worldwide HIV/AIDS pandemic, with a staggering 23.2 million adults and children living with HIV and 2.4 million newly infected individuals in 2013 (World Health Organization 2014). Sub-Saharan Africa represents only 12 % of the global population but accounts for 68 % of all HIV infections and 70 % of new infections in 2010 (United Nations AIDS 2014).

Individuals living with HIV/AIDS must cope not only with chronic physiological hardships associated with the destructive disease, but must also simultaneously struggle with a myriad of psychological, social, spiritual, and financial stressors. These stressors may lead to emotional distress, uncertainty, helplessness, anxiety, depression, anger, hatred, suicide, and even revenge (Antoni 2003; Antoni et al. 1991; Bor et al. 1993; Grace 1994; Parsons et al. 2005; Shacham et al. 2008). Such psychological problems may actually perpetuate high-risk behaviors, which can also fuel the spread of HIV/AIDS. Thus, the availability and utilization of supportive counselling aimed at facilitating adjustment to ongoing stress and helping to address psychological problems is critical in dealing with the HIV epidemic.

Since the widespread availability of antiretroviral medicine, AIDS does not have to be a short-range death threat. Thus, clients now have to deal with the fact that, if medicine is available, they will not die an early death from AIDS; however, medicine adherence is critical to long-term survival. Because of this, the role of the counsellor has evolved to focus primarily on assisting clients as they adjust to living for the rest of their lives with a chronic disease.

Counselling sessions following the HIV positive diagnosis are designed to help clients avoid infecting others and to help them better cope with issues arising from being HIV positive. Although HIV/AIDS mental health counselling has been shown to play a crucial role in reducing mood disturbances and promoting social support and healthy coping, while reducing high risk behaviors (Hoffman 1996), most of the research has been conducted in Western countries (Freeman 2003). The World Health Organization and UNAIDS have not only called for increased mental health treatment of those affected by the disease, but have also called for increased advocacy and research in areas severely impacted by AIDS, including Sub-Saharan Africa (World Health Organization 2014).

A very limited number of studies have focused on HIV/AIDS counselling in Sub-Saharan Africa. Of the studies available, most have focused on counsellors. Richards and Marquez (2005), for example, conducted interviews with eight Zimbabwean HIV/AIDS counsellors and concluded that, in the perceptions of those interviewed, HIV/AIDS counsellors in Zimbabwe were undertrained and received little in the way of support, supervision, and ongoing training. The findings also suggested that counsellors found the early and later stages of HIV/AIDS counselling to be the most difficult, along with working with couples who were serodiscordant and couples wanting children. These counsellors also reported a mixture of positive and negative psychological reactions associated with counselling HIV/AIDS clients. Richards and Marquez concluded that Zimbabwean HIV/AIDS counsellors appeared to be under extreme stress from their jobs but, despite this stress, they had found personal meaning in their helping efforts.

Grinstead and Van Der Straten (2000) conducted focus groups and individual interviews with 11 counsellors and counsellor supervisors in Kenya and Tanzania. They concluded that the counsellors found their jobs both rewarding and stressful and that they perceived pressure to provide helpful information to their clients and also to be good role models in their communities. Additional stresses were related to HIV issues in the personal lives of these counsellors.

A few studies of HIV-positive clients in Sub-Saharan Africa have been reported. Shacham et al. (2008) administered questionnaires to 397 clients in western Kenya who were HIV-positive and had self-enrolled in one or more psychosocial support groups. The questionnaire was designed to collect data related to participants’ demographic and HIV-related characteristics, and also included assessments of psychological distress. The authors reported that participants were primarily female (72 %), that 70 % were unemployed, and that participants had been living with HIV for an average of 2.5 years. They also reported that, across all participants, HIV status was rarely shared with sex partners, family members or friends and that psychological distress was more prevalent among women on measures of depression, anxiety, paranoid ideation, interpersonal sensitivity, and somatization.

Edwards and Edwards (2009) studied 30 HIV-positive clients in South Africa who received six one-hour sessions of person-centered group counselling. Compared to a student control group, the HIV-positive clients showed improvements in perceptions of autonomy, personal growth, environmental mastery, positive relations with others, and self-acceptance.

Though limited in number, these studies of clients and counsellors in Sub-Saharan Africa suggest that supportive counselling has the potential to be effective in helping HIV-positive individuals lead higher quality lives. However, the counselling profession in these countries tends to be at an early stage of development and much work will be needed to improve the quality of counsellor training and supervision and the scope and quality of client services. In order to promote such improvement, additional research is needed to more fully evaluate the current state of supportive counselling services in Sub-Saharan countries. Since very few studies have assessed the perspectives of HIV-positive clients who are receiving counselling services, this seems to be a key area for further research.

The present study focuses on HIV/AIDS clients in Botswana and how they perceive the quality and scope of supportive counselling services they have received. In Botswana, an estimated 320,000 people are currently living with HIV, including approximately 24.8 % of adults aged 15–49. In addition to those infected with HIV, there are also an estimated 93,000 orphans who have been victimized by this pandemic (United Nations AIDS 2014).

Since 1999 the Government of Botswana has expanded its response to HIV/AIDS and is striving to provide comprehensive care that includes the provision of free antiretroviral (ARV) treatment to those in need. However, as Allen and Heald (2004) noted, an ARV treatment program can only be impactful if people overcome their reluctance to being tested and treated. Ultimately, the success of such a treatment program will increase the prevalence of those living with HIV and needing ongoing care from counselling, social work, medical and related professionals.

In response to the long-term psychological care needs of those living with HIV, Botswana has begun to provide supportive mental health services through hospitals, counselling clinics and non-governmental organizations, with these services often linked directly to HIV/AIDS issues such as pre-ARV therapy counselling (Stockton et al. 2010).

Two relatively recent studies of HIV/AIDS counselling in Botswana - Stockton et al. (2012) and the International Training and Education Center for Health Report to the Ministry of Health (I-TECH 2011) - have shed light on the counsellors’ views on their role as well as their training. The I-TECH (2011) in Botswana conducted an evaluation of lay counsellors and their duties. The study concluded that lay counsellors’ duties had been widely expanded past their job description to include assisting with Child Welfare clinics, dispensing medications, compiling reports, and dressing wounds. As lay counsellor duties had expanded, they had less time to focus on the tasks they were hired to perform. Overall, lay counsellors had a positive outlook on their work and job performance. Clients also had mostly positive feedback, with the majority of suggestions focused around a need for shorter wait times.

Stockton et al. (2012) surveyed 181 HIV/AIDS counsellors in Botswana to gauge their perceptions of the training and supervision they received, along with their perceptions of their own effectiveness, how they dealt with social stigma, and their psychological reactions to working with HIV-positive clients. Their major conclusions were that HIV/AIDS counsellors in Botswana were very satisfied with their training and perceived themselves to be effective in working with clients. The authors of the study did note, however, that the vast majority of the counsellors had received 8 weeks or less of formal training and field experience, with over 80 % reporting no on-the-job supervision in an average month, 75 % indicating that they had too many clients to work with effectively, and the majority of counsellors reported feelings of stress and burnout related to their work. Additionally, the counsellors indicated that they desired more access to learning materials to help them increase their counselling knowledge and skill. The study prompted significant improvements in the training of counsellors and their working conditions.

The current study seeks to expand on the Stockton et al. (2012) study of HIV/AIDS counsellors in Botswana by assessing the perceptions of HIV clients who are receiving counselling services. Findings may also be relevant to counsellor training and client services and benefits in other Sub-Saharan countries. This study employed a survey to assess the perceptions of Botswana HIV/AIDS clients in regard to the supportive counselling they had received. More specifically, the study addressed client reactions to the following general areas: a) their personal support system, (b) the goal setting process, (c) HIV/AIDS educational materials, (d) sharing their HIV status with others, (e) benefits of counselling and related services, (f) their current quality of life, (g) their perception of the counselling relationship, (h) access to counselling and support services, and (i) dealing with the social stigma of being HIV-positive.

Method

Participants

Inclusion criteria for participation in the study required respondents to be at least 18 years of age, HIV-positive, and receiving supportive counselling at the time of the study. Participants included 188 females and 131 males (9 missing values). Fourteen participants were in the 18–25 age bracket, 66 in the 26–35, 111 in the 36–45, 105 in the 46–55, 27 in the 56–65, and 4 were 66 years of age or older (1 missing value). The numbers of participants who reported each highest level of education category were as follows: 137 no formal education, 101 Junior Secondary, 53 Senior Secondary, 14 Certificate, 14 Diploma, 5 Bachelors Degree, and 1 Masters Degree (3 missing values). Participants included 82 living in urban/city areas, 112 in peri-urban/town areas, and130 in rural/village areas (4 missing values). Participants reported their work status as: 78 not employed, 133 working full-time, 49 working part-time, and 66 self-employed (2 missing values). Participants reported knowing about their HIV-positive status for an average of 6.92 years (SD = 3.61).

Survey Instrument

A survey instrument was developed and pilot-tested for the study. Based on the advice of Botswana colleagues and officials, the survey was composed in English, since English is one of the two national languages in Botswana and is taught in the schools. The survey included two sections: (i) a participant information section, and (ii) a Likert-type item-rating section.

Participants were assured that their survey responses would be confidential and were instructed not to put their names on any part of the instrument. Participants were encouraged to respond to as many questions as possible, though they could skip any questions they felt uncomfortable answering. The participant information section requested information such as the participant’s age, gender, education level, employment status, and participation in counselling and related services. The item-rating section of the survey included 50 statements for participants to rate on a 5-point (Strongly Disagree - Strongly Agree) scale, with each item also including an option for “Does Not Apply”.

Procedure

The study was approved by officials at both the Ministry of Health in Botswana and the Indiana University Institutional Review Board. The following Botswana population centers were selected for the study: Gaborone, Francistown, Masunga, Tutume, Maun, Mahalapye, Palapye, Selibe-Phikwe, Molepolole, Loabtse, and Kanye. Within these population centers, random sampling was used to select a total of 25 hospitals/clinics for the study. Volunteers were then solicited from clients who met the study’s inclusion criteria as earlier stated.

Trained employees of the Institute for Development Management (IDM), the major institution in Botswana training HIV/AIDS paraprofessional counsellors, traveled to each selected hospital/clinic and explained the proposed study and consent procedure to potential participants. Those who agreed to participate signed a consent form and were given a survey instrument to complete.

During the initial data collection it was discovered that the study protocols for collecting data had not been properly followed at two of the district sites. In these two districts the survey assistant read the survey to respondents and ticked the survey responses for them, thus confidentiality was compromised and likely influenced their responses. Thus those data were excluded from the study and new data were collected in those districts following correct procedures.

A total of 329 clients read and signed the consent form and self-administered the survey, though one was excluded from the study due to completing less than half of the survey. Thus, a total of 328 usable surveys were analyzed.

Results

A total of 209 participants (64 %) reported that they had received only 1–3 counselling sessions since being diagnosed as HIV-positive, 63 (19 %) reported 4–6 sessions, 30 (9 %) reported 7–10 sessions, and 22 (7 %) reported 11 or more sessions (4 missing values). Seven participants (2 %) reported that they received supportive counselling 1 or more times per week, 19 (6 %) reported counselling 1 or 2 times per month, 196 (60 %) reported that counselling was not received by them on a regular basis, and 97 (30 %) participants indicated “other” in this regard (9 missing values). Ninety- five participants (29 %) indicated that their counselling sessions typically lasted less than 15 min, 144 (44 %) reported their sessions lasted 16–30 min, and 84 (26 %) reported sessions lasting more than 30 min (5 missing values). The numbers of participants reporting various types of counselling received included 156 (48 %) receiving individual counselling, 203 (62 %) receiving group counselling, 53 (16 %) receiving couples counselling, and 62 (19 %) receiving family counselling (some participants indicated they had received more than one type of counselling).

Client responses to the 50 Likert-type items were initially analyzed by determining the frequency and percentage of participants who rated each item across the five ‘Strongly Disagree - Strongly Agree’ categories. These data are presented in Table 1 with items grouped under the original nine item categories used in constructing the instrument.

Table 1 Survey item response category frequencies and percentages
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Eighteen of the survey items assessed participants’ reactions to the benefits they felt they had received through counselling and related services. Participants were generally positive about the benefits they had received, with at least 74 % agreeing or strongly agreeing to 13 of the 18 positively worded items (percentages of Agree or Strongly Agree for items did not include missing data or NA responses in the calculations). Participants were particularly positive (Agreeing or Strongly Agreeing) concerning help with understanding how one can benefit from counselling (94 %), taking medication regularly (98 %), practicing safe sex (97 %), staying motivated (92 %), learning about secondary infections (92 %), and learning how to protect children against HIV (94 %).

Less than 50 % of participants Agreed or Strongly Agreed with items related to dealing with financial worries (9 %), work issues (19 %), and grief when a family member or friend has died (43 %). However, it should be noted that there were a large numbers of missing data or NA responses for these three items: 35 for financial worries; 103 for work issues; and 41 for grief issues.

Nine items assessed participants’ reactions to the counselling relationship. Participants were generally positive on these items with 60 % or more Agreeing or Strongly Agreeing with seven of the positively worded items. Participants were particularly positive (Agreeing or Strongly Agreeing) concerning having confidentiality explained to them (90 %), feeling accepted by the counsellor (94 %), and seeing the counsellor as knowledgeable about HIV/AIDS (96 %). Fewer participants Agreed or Strongly Agreed with items concerning counsellor dependability (57 %) and feeling that their cultural background was respected (49 %).

Two items related to participants’ satisfaction with HIV/AIDS educational materials. On one item, 72 % Agreed or Strongly Agreed that the educational materials helped them more easily discuss their HIV status with their partner or family. On the other item, 80 % Agreed or Strongly Agreed that the educational materials were clear and understandable.

Six items assessed reactions to ease of access for counselling and support services. At least 73 % of the participants Agreed or Strongly Agreed with five of these positively worded items and were particularly positive (Agreeing or Strongly Agreeing) concerning the ease of getting HIV-related medication (94 %) and confidence that their records would be kept private (90 %). However, only 52 % Agreed or Strongly Agreed that, in a crisis, they could meet with a counsellor within a day or two.

Three items related to participants’ reactions to the goal setting process in counselling. Sixty-three percent Agreed or Strongly Agreed that they had learned to set better goals in counselling and 57 % Agreed or Strongly Agreed that they were very confident they could accomplish the goals they set in counselling. However, only 47 % Agreed or Strongly Agreed that they set goals together with their counsellor.

Three items assessed participants’ reactions to support from family and friends. At least 78 % Agreed or Strongly Agreed with all three positively worded items and were particularly positive (90 % Agreed or Strongly Agreed) about being accepted by family even though they were HIV-positive. Three items also assessed participants’ reactions to sharing their HIV status with others. At least 70 % Agreed or Strongly Agreed with two of the positively worded items, while only 31 % Agreed or Strongly Agreed that they had been able to talk with their employer about their HIV status.

Three positively worded survey items assessed participants’ reactions to their present quality of life. Seventy-eight percent Agreed or Strongly Agreed that they were currently leading a productive life, 80 % Agreed or Strongly Agreed that they were good at dealing with feelings about being HIV-positive, and 74 % Agreed or Strongly Agreed that they currently felt confident about handling problems in their life. Three negatively worded items related to participants’ reactions to social stigma issues in their life. Thirty-five percent of participants Agreed or Strongly Agreed that they were ashamed for others to know they were HIV-positive, while 38 % Disagreed or Strongly Disagreed with this item. Eighty-three percent Agreed or Strongly Agreed that they believed many people have a bad opinion of HIV-positive people, while only 8 % Disagreed or Strongly Disagreed with this item. Fifty-seven percent Agreed or Strongly Agreed that people treated them differently when they knew that they were HIV-positive, while only 21 % Disagreed or Strongly Disagreed with this item.

A second stage of data analyses utilized Principal Component Analysis (PCA) to determine if meaningful components could be identified among the 50 Likert-type items. PCA is closely related to factor analysis and seeks to reduce a high dimensional data-set to a smaller number of dimensions or components. This data reduction procedure groups into components items that are measuring the same construct and makes it possible to represent the components with single scores (Tabachnick and Fidell 2001).

Participants’ responses to the Strongly Disagree - Strongly Agree scales were converted to a numerical 1–5 scale for the PCA. Normality was assessed using skewness and kurtosis statistics, and linearity was examined through scatter plots. There was no compelling reason to transform any of the data to improve normality. Pairwise deletion of missing data was used for the analysis and the negatively worded items (items 43, 44, and 45 were reverse scored).

Principle Component Analysis with Promax (oblique) rotation provided the most interpretable component structure (Kaiser-Meyer-Olkin measure of sampling adequacy = .88; Bartlett’s test of sphericity significant at .00). A total of 12 components with eigenvalues above 1.00 were identified; however, only five components had at least three items and Cronbach alpha levels deemed strong enough for further analysis. Table 2 displays the rotated component matrix values for items included in each of the five components selected for further analysis.

Table 2 Component structure for survey items
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The seven items in the first component focused on participants’ perceived helpfulness of the counsellor and the counselling process, and was named ‘Counsellor/Counselling Helpfulness’ (HELPFULNESS). The second component included seven items focused primarily on participants’ current outlook on their lives and was named ‘Current Outlook on Life’ (OUTLOOK). The third component included three items focused on the goal setting process in counselling and was named ‘Goal Setting’ (GOAL SETTING). Component four had three items focused on participants’ reactions to social stigma issues in their lives and was named ‘Social Stigma’ (SOCIAL STIGMA). The fifth component was represented by three items focused on participants’ perceived acceptance by family and friends and was named ‘Acceptance by Family/Friends’ (ACCEPTANCE).

The alpha internal consistency coefficients for the five components were as follows: HELPFULNESS = .89; OUTLOOK = .87; GOAL SETTING = .77; SOCIAL STIGMA = .71; and ACCEPTANCE = .77. The validity of these scales, for the purpose of this study, is supported by the fact that the items within each component were similar in focus and each component closely matched with one of the topic categories the instrument was designed to assess, thus supporting both face validity and construct validity of the scales.

Component-based scores were derived by averaging the items within each component. SOCIAL STIGMA items were negatively worded on the survey (these items were reverse scored for statistical analyses), while items for the remaining four components were all positively worded. Component scores could range from 1 (Strongly Disagree) to 5 (Strongly Agree), with higher scores indicating more positive ratings on all components. Table 3 displays the means, standard deviations and zero-order intercorrelations among the five component scores.

Table 3 Means, standard deviations and intercorrelations among component scores
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The component scores generally had low to moderate intercorrelations, though HELPFULNESS and OUTLOOK were correlated somewhat higher at .62, as was HELPFULNESS and ACCEPTENCE at .49, and OUTLOOK and ACCEPTANCE at .53. Additional analyses explored relationships among the five component scores and selected demographic variables of the study using correlation and ANOVA procedures with Tukey’s HSD multiple comparison test where appropriate.

There was one significant correlation between a demographic variable and component scores. Participants who had known of their HIV-positive status for more years had higher ratings on HELPFULNESS (r = .30, p < .01), OUTLOOK (r = .27, p < .01), GOAL SETTING (r = .23, p < .01), and ACCEPTANCE (r = .18, p < .01). However, participants who had known of their HIV-positive status for more years responded with lower ratings on SOCIAL STIGMA (r = −.15, p < .01); thus, they perceived that they faced greater social stigma issues.

ANOVA comparisons revealed no significant relationships between participants’ age or education level across any of the five component scores. Females and males differed on measures of OUTLOOK, F(1296) = 5.03, p < .05, ƞ 2 = .02, and ACCEPTANCE, F(1296) = 6.40, p < .05, ƞ 2 = .02. Females rated OUTLOOK (M = 4.15, SD = .60) and ACCEPTANCE (M = 4.29, SD = .64) more positively than did males (M = 3.98, SD = .76 and M = 4.08, SD = .78 respectively).

The analysis of participants’ living areas revealed significant differences related to HELPFULNESS, F(2220) = 54.35. P < .01, ƞ 2 = .33, OUTLOOK, F(2299) = 10.49, p < .01, ƞ 2 = .07, SOCIAL STIGMA, F(2314) = 27.89, p < .01, ƞ 2 = .15, and ACCEPTANCE, F(2300) = 5.62, p < .01, ƞ 2 = .04. Participants living in rural/village areas (M = 3.39, SD = .34) rated HELPFULNESS higher than did those from urban/city (M = 3.16, SD = 1.02) or peri-urban/town areas (M = 2.65, SD = 1.01), and those from urban/city areas had ratings higher than those from peri-urban/town areas. Participants from rural/village areas (M = 4.26, SD = .48) rated OUTLOOK higher than those from peri-urban/town areas (M = 3.86, SD = .73). Participants from peri-urban/town areas (M = 2.88, SD = .87) rated SOCIAL STIGMA higher than those from either urban/city (M = 2.23, SD = 1.08) or rural/village areas (M = 1.99, SD = .88); indicating that participants from peri-urban/town areas perceived less social stigma in their lives. Participants from rural/village areas (M = 4.32, SD = .70) had higher ACCEPTANCE ratings than did those from peri-urban/town areas (M = 4.01, SD = .69).

There were significant differences between categories of marital status on ratings of HELPFULNESS, F(4221) = 4.36, p < .01, ƞ 2 = .07, with single (M = 3.56, SD = .89) and married (M = 3.51, SD = .92) individuals having higher ratings than cohabitating individuals (M = 2.98. SD = .99).

Four categories of types of employment were compared on component scores. Significant differences were found for OUTLOOK, F(3300) = 6.07, p < .01, ƞ 2 = .06, GOAL SETTING, F(3305) = 4.08, p < .01, ƞ 2 = .04, and SOCIAL STIGMA, F(3315) = 3.71, p < .05, ƞ 2 = .03. Self-employed (M = 4.28, SD = .45) and full-time workers (M = 4.16, SD = .63) both rated OUTLOOK higher than did those who were employed part-time (M = 3.78, SD = .81), and no significant differences involved those who were not employed. Self-employed workers (M = 3.79, SD = .46) rated GOAL SETTING higher than did part-time workers (M = 3.42, SD = .77), full-time workers (M = 3.48, SD = .61), and those not employed (M = 3.50, SD = .78). Part-time workers (M = 2.72, SD = .95) rated SOCIAL STIGMA higher than did full-time workers (M = 2.17, SD = .99); indicating that part-time workers perceived less social stigma.

Six categories of family income were compared across the five component scores. Significant differences were found for HELPFULNESS, F(5218) = 13.05, p < .01, ƞ 2 = .23, OUTLOOK, F(5297) = 10.27, p < .01, ƞ 2 = .15, GOAL SETTING, F(5302) = 3.03, p < .05, ƞ 2 = .05, SOCIAL STIGMA, F(5312) = 6.86, p < .01, ƞ 2 = .10, and ACCEPTANCE, F(5298) = 4.05, p < .01, ƞ 2 = .06. Those with family incomes of 30 k pula per year (around US$3 k) or more (M = 4.03, SD = .31), those between 20 k and 30 k pula (M = 3.89, SD = .50), and those between 10 k and 20 k pula (M = 3.90, SD = .48) all rated HELPFULNESS higher than those with family incomes between 5 k pula and 10 k pula (M = 2.93, SD = 1.12), between 2 k pula and 5 k pula (M = 2.92, SD = 1.06), or those with family incomes below 2 k pula per year (M = 3.10, SD = 1.01).

Those with family incomes of 30 k pula per year or more (M = 4.55, SD = .38), those with 20 k to 30 k pula per year (M = 4.38, SD = .49), and those with 10 k to 20 k pula per year (M = 4.28, SD = .46) all rated OUTLOOK higher than did those with family incomes of 5 k to 10 k pula (M = 3.98, SD = .52), 2 k to 5 k pula (M = 3.85, SD = .65) or those with incomes of less than 2 k pula per year (M = 3.87, SD = .80). Those with yearly family incomes of 30 k pula or more (M = 3.85, SD = .56) rated GOAL SETTING higher than did those with incomes between 5 k pula and 10 k pula (M = 3.37, SD = .54) or those with incomes less than 2 k pula (M = 3.43, SD = .71).

For SOCIAL STIGMA, those with family incomes of 5 k to 10 k pula (M = 2.77, SD = 1.08), 2 k to 5 k pula (M = 2.60, SD = 1.02) and less than 2 k pula (M = 2.49, SD = 1.01) all had higher ratings than those in the 10 k to 20 k pula group (M = 1.71, SD = .62). Also, those in the 5 K to 10 K pula group and the 2 k to 5 k pula group had higher ratings than those with yearly family incomes of 20 k to 30 k pula per year (M = 2.06, SD = .81). For the final component, ACCEPTANCE, those with yearly family incomes of 20 k to 30 k pula (M = 4.53, SD = .51) had higher ratings than those with 2 k to 5 k pula (M = 4.02, SD = .69) or those with less than 2 k pula incomes (M = 4.08, SD = .78) (see Fig. 1).

Fig. 1
figure 1

Mean component scores for helpfulness, outlook, goal setting, social stigma and acceptance by family income level

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Participants were asked how long their counselling sessions typically lasted and these categories were compared across the five component scores. Significant differences were found for all five components as follows: HELPFULNESS, F(4216) = 29.23, p < .01, ƞ 2 = .35, OUTLOOK, F(4296) = 15.27, p < .01, ƞ 2 = .17, GOAL SETTING, F(4302) = 5.85, p < .01, ƞ 2 = .07, SOCIAL STIGMA, F(4311) = 10.60, p < .01, ƞ 2 = .12, and ACCEPTANCE, F(4297) = 6.64, p < .01, ƞ 2 = .08. Participants whose counselling sessions lasted more than 60 min (M = 3.96, SD = .43), 41–60 min (M = 3.87, SD = .45), 31–40 min (M = 3.90, SD = .40), and 16–30 min (M = 3.70, SD = .79) had HELPFULNESS ratings higher than did those whose sessions lasted 15 min or less (M = 2.52, SD = .94). Participants whose counselling sessions lasted more than 60 min (M = 4.14, SD = .62), 41–60 min (M = 4.47, SD = .47), 31–40 min (M = 4.42, SD = .76), and 16–30 min (M = 4.20, SD = .57) all rated OUTLOOK higher than did those whose sessions lasted 15 min or less (M = 3.70, SD = .68).

For GOAL SETTING, participants whose counselling sessions lasted more than 60 min (M = 3.88, SD = .53) had higher ratings than those whose sessions lasted less than 15 min (M = 3.29, SD = .67). Participants who reported sessions of less than 15 min (M = 2.62, SD = .96) or 16–30 min (M = 2.52, SD = .95) rated SOCIAL STIGMA higher than did those whose sessions lasted 41–60 min (M = 1.78, SD = .91) or those whose sessions lasted more than 60 min (M = 1.51, SD = 1.01). Participants whose counselling sessions lasted more than 60 min (M = 4.29, SD = .70), 41–60 min (M = 4.35, SD = .82), 31–40 min) M = 4.47, SD = .62), and 16–30 min (M = 4.32, SD = .66) all rated ACCEPTANCE higher than did those whose sessions lasted 15 min or less (M = 3.90, SD = .74) (see Fig. 2).

Fig. 2
figure 2

Mean component scores for helpfulness, outlook, goal setting, social stigma and acceptance by length of counselling sessions

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Discussion

Participants’ responses indicated that, overall, they were quite positive about the benefits they received from supportive counselling. This was despite the fact that the majority reported having received three or fewer counselling sessions since being diagnosed as HIV-positive. In their survey of HIV/AIDS counsellors in Botswana, Stockton et al. (2012) reported that several counsellors indicated that having too many clients was a barrier to effective counselling services and this may account in part for the small number of sessions per client. Thus, even though most participants had received only a few counselling sessions, they were positive about the benefits derived from those sessions. Participants were particularly positive about learning what counselling could do for them, staying motivated, understanding the importance of taking medication, learning to practice safe sex, learning about secondary infections, and learning how to protect their children against HIV infection. These items appear to fit within the pychoeducational aspect of supportive counselling and it appears that this may be a primary area of focus for HIV/AIDS counselling in Botswana.

Participants’ reactions were markedly less positive concerning being helped in dealing with work issues and financial worries. One possibility is that work and financial issues have not traditionally been a primary focus of counselling in Botswana, though it may also be that most clients had not had enough sessions to move beyond issues more directly related to their HIV/AIDS status.

Participants were very positive concerning their relationship with their counsellor. Although slightly less than half of respondents agreed or strongly agreed that their counsellor respected their cultural background, the majority of participants were positive in their ratings of the remaining eight counselling relationship items. It seems surprising that less than half of the participants felt that their cultural backgrounds were respected, given their high ratings on other relationship items; in particular, over 90 % of participants agreed or strongly agreed that their counsellor accepted them for who they were. One possibility is that participants viewed acceptance in terms of their personal relationship with the counsellor and viewed respect for their cultural background more in terms of the counsellor’s ability to understand their tribal, religious, or other background factors.

Participants indicated a high level of satisfaction with the HIV/AIDS educational materials they had received, indicating that these materials helped them discuss their HIV status with their partners and/or family and that the materials were clear and understandable. Although only two items assessed participants’ reactions to educational materials, it appears that they are an effective aspect of counselling in Botswana. Participants were also very positive about their access to counselling support services. They were particularly positive about such things as having easy access to HIV medication, feeling confident their records would be kept private, and being able to receive counselling at a convenient location. Ratings were somewhat less positive, concerning being able to meet with a counsellor within a day or two if experiencing a crisis; however, this may well relate to the issue of counsellors being hindered by having too many clients, as noted by Stockton et al. (2012) in their study of counsellors in Botswana.

Participants generally had positive perceptions of the goal setting process in counselling, though somewhat less positive than most of the other areas surveyed. Slightly less than half of the participants agreed or strongly agreed that they and their counsellor set goals together, although the majority of participants agreed or strongly agreed that they learned to set better goals and felt confident they could accomplish goals set in counselling. It appears that goal setting was occurring and was successful to some extent in the counselling sessions, though it may not be emphasized to the same extent as was the pychoeducational component of supportive counselling.

Participants were quite positive concerning their family and friends support system, indicating that they felt accepted even though being HIV-positive and could depend on family and friends for help when needed. Participants were particularly positive about being accepted by their family; thus it may be useful for counsellors to directly involve key family members in the treatment of their HIV/AIDS clients. In terms of sharing their HIV status with others, a majority of participants indicated that counselling had helped them be more open when appropriate and that they had been able to talk honestly with their spouse or sexual partner about their status. These positive ratings may well be related to the high level of support participants felt from their family and friends. The majority of participants did, however, disagree or strongly disagree that they were able to talk with their employer about their HIV status. This finding does not seem surprising as it likely relates to a fear of losing one’s job if their employer learned that they were HIV-positive and, additionally, participants in general may not have felt they had the type of close personal relationship with their employer, where sharing their HIV status would be appropriate.

Participants’ ratings indicated that a large majority felt positive about their present quality of life. This seems to indicate that most of the participants had dealt, at least to a fair degree, with typical initial feelings of fear and distress over being HIV-positive. Thus, for the majority of participants it could be inferred that they had largely moved through the crisis phase and were ready to benefit from supportive counselling efforts.

The social stigma items were negatively worded on the survey instrument, thus agreement would indicate that social stigma was more of an issue, while disagreement would indicate that it was less of an issue. The majority of participants indicated that they believed that others treated them differently when they knew of their HIV status, and that many people had a bad opinion of HIV-positive people. Participants were more balanced in terms of indicating that they were ashamed for others to know they were HIV-positive, with approximately equal numbers of participants agreeing and disagreeing with this item. Overall, it appears that the majority of participants felt at least somewhat stigmatized by being HIV-positive, and this may be a key area of focus for supportive counselling, since it likely relates closely to client motivation, confidence, and quality of life.

Discussion of Component Score Results

There were several significant findings relating demographic variables to the component-based scores that emerged from the Principle Component Analysis. Participants who had known of their HIV-positive status for more years were more positive about counsellor/counselling helpfulness, current outlook on life, goal setting, and acceptance by family/friends than were those who had known of their status for fewer years. It may be that, given more time, participants were able to put their HIV-positive status into better perspective and, thus, were more ready to benefit from counselling and adopt a more positive outlook on life. In contrast, participants who had known of their HIV-positive status for more years reported greater social stigma issues. One possibility is that those who were HIV-positive in the earlier years of the disease may have faced greater social stigma and have carried these negative feelings forward.

Females in the study reported a more positive outlook on life and higher levels of acceptance by family/friends than did males (though ratings by males were still well above the midpoint of the 5-point scale). This difference may be related to the tendency of women in Botswana to be more open about their HIV status and other conditions with their families and close friends than is true for men (Paul, Personal communication); thus they may have more social support as a result of their disclosures. Additionally, women in Botswana are commonly believed to have higher levels of health-seeking behaviors than men (Paul, Personal communication), and this may have a positive influence on their life outlook and feelings of acceptance.

Participants from rural/village areas were more positive concerning counsellor/counselling helpfulness than were those from peri-urban/town or urban/city areas, and more positive concerning current outlook on life and acceptance by family/friends than were those from peri-urban/town areas. Participants from rural/village areas likely have less easy access to counselling, health and related facilities and, thus, may have a tendency to view them more positively when they do receive those services. Participants from rural/village areas also may tend to have a smaller and more close-knit family/friends support network and this dynamic may promote a more positive outlook on life and feelings of acceptance. Participants from peri-urban/town areas reported less social stigma than did those from other areas. This finding is more difficult to explain, though it may be that the peri-urban/town environment provides the right balance of family/friend support and anonymity so that social stigma is less of an issue than in rural/village or urban/city areas. It also might be that people in urban/city areas live a “mind-your-own-business sort of life” and also that the fruits of public education against stigma are beginning to show, since most interventions start in urban/towns.

Single or married participants viewed counselling as more helpful than did those who were cohabitating with a partner. This isolated finding should be considered cautiously; however, one possibility is that there may tend to be relationship issues unique to cohabitating that complicate, hinder or sidetrack supportive counselling efforts.

Participants who were self-employed or full-time employed were more positive in their outlook on life than were those who were employed part-time. This finding may stem from the fact that self-employed and full-time workers likely have a more stable financial outlook that, in turn, affects their overall outlook on life. Self-employed participants were also more positive about the goal setting process than were part-time workers, full-time workers, or those not employed. One possibility is that self-employed participants’ success depends more on their own efforts and decisions than is true for others and, thus, they may tend to be more goal-oriented in general, which leads them to value the goal setting process in counselling.

Participants who were employed part-time reported less social stigma than did those employed full-time, though it should be noted that the proportion of variance explained was very small. One possibility is that part-time workers, by virtue of spending less time among co-workers, were better able to keep their HIV-positive status private within the work setting.

Participants with family incomes of more than 10 k pula per year were more positive about counsellor/counselling helpfulness and their outlook on life than were those with family incomes of less than 10 k pula per year. Though not as consistent, those with higher levels of family income also tended to be more positive about the goal setting process and acceptance by family/friends. With the exception of social stigma, it appears that having a family income above 10 k pula per year is an important factor leading to greater satisfaction with counselling and life in general for the HIV-positive participants in this study. One explanation is that those with higher family incomes tended to have more access to information, resources, and other networks of support.

A follow-up analysis of the data revealed that 52 % of participants with family incomes above 10 k pula per year reported having had more than three counselling sessions since being diagnosed as HIV-positive, while only 24 % of participants with family incomes below 10 k pula per year reported more than three sessions. Additionally, 88 % of the higher income level participants reported having counselling sessions lasting more than 15 min while only 57 % of lower income participants reported sessions lasting more than 15 min. Thus, the more positive ratings by higher family income participants is likely due, at least in part, to the fact that they tended to have more counselling sessions for longer periods of time each session. Another finding was that those with less than 10 k pula family incomes tended to report less social stigma than did those at higher income levels. One explanation for this finding is that individuals at higher income levels, due to social status pressures, may simply experience greater social stigma than is true for those at lower income levels. Alternatively, higher income level individuals may be more sensitive to social stigma cues.

Participants reporting counselling sessions lasting more than 15 min provided more positive ratings of counsellor/counselling helpfulness, current outlook on life, and acceptance by family /friends than did those receiving less than 15 min of counselling per session. Participants having sessions of 60 min or longer were more positive about the goal setting process than were those having sessions of 15 min or less. Twenty-nine percent of participants reported that their counselling sessions typically lasted for 15 min or less, thus this appears to be an important finding. It is not surprising that clients typically receiving very brief counselling sessions would perceive less help and life benefits from the counselling experience. Such brief sessions allow little time for developing the therapeutic relationship, encouraging client motivation and behavior change, and delving deeper into the significant issues faced by HIV-positive individuals. By contrast, participants receiving 15 min or less sessions reported less social stigma. One possible explanation is that very brief counselling sessions do not tend to allow enough time to fully explore issues related to social stigma and clients may not feel comfortable talking about such issues if they have not spent enough time with their counsellor. Thus, clients receiving such brief counselling sessions may not have fully faced their reactions to social stigma issues and were less aware of such issues in their lives. This would not, however, guarantee that these clients were not affected by social stigma in a negative manner.

Limitations of the Study

In any study there are limitations that call for caution when interpreting and generalizing the findings. In the present study there were a moderate number of missing values that represented respondents skipping questions and, for a few items, a large number of participants who indicated that the item was not applicable. These missing data could potentially have skewed the results somewhat. The sample of HIV-positive clients was smaller than is ideal and, while the clinic and hospital sites were randomly chosen, the clients themselves were recruited on a volunteer basis rather than randomly. Thus, clients with particularly positive or negative views of their counselling experience may have been more inclined to volunteer. Because of such limitations, caution should be used in generalizing the findings beyond the sample of participants surveyed.

Conclusions and Recommendations

With the exception of social stigma, participants were moderately to highly positive concerning their reactions to all of the survey categories as well as the five component scores. They were particularly positive about the HIV educational materials they received, their current quality of life and the support/acceptance received from family and friends. This suggests that the participants in the study were generally happy with their supportive counselling services and that they viewed their current lives in a positive manner.

The findings also highlight a few areas that likely warrant further study and attention. The vast majority of participants reported having three or fewer counselling sessions since learning of their HIV-positive status, and less than 10 % reported receiving counselling more than once per month. Additionally, a large proportion of the participants reported that their counselling sessions typically lasted 15 min or less. Given the complex nature of psychological, behavioral, and emotional issues faced by HIV-positive individuals, it seems likely that clients are not getting the maximum benefit possible with such brief and irregular counselling sessions.

Social stigma issues appear to be at least of moderate concern to many of the participants and such issues may be something that counselling can address in greater depth. The findings also suggest that counselling in Botswana does not typically focus on such things as work issues and financial worries that clients may face. These types of issues can greatly affect clients’ happiness and quality of life and may be another important area for increased attention.

Participants were generally quite positive concerning their relationship with their counsellor; however, more than half did not agree that the counsellor respected their cultural background. As discussed earlier, it may be that clients felt the counsellor did not fully understand such things as their tribal, religious, and other life background factors. Counsellor respect is a key factor in developing a positive counsellor-client relationship, which serves as a springboard to productive therapeutic work and client motivation. Therefore, this may be an important area for further study and attention.

Participants with higher family incomes, particularly those with 10 k pula per year or higher, had more positive ratings on all of the component scores except for social stigma. This may be attributed to a variety of factors; however, two key factors may be that those with higher levels of income tended to have received more counselling sessions and with sessions lasting for longer periods of time. The realities of lower income living may well limit clients in terms of access to counselling and related services and may negatively impact their outlook on life. However, the majority of participants in this study fell into the lower income brackets, thus it seems important to address this discrepancy between higher and lower income clients.

The findings of this study indicate that participants who received 15 min or less per counselling session were significantly less positive about counsellor/counselling effectiveness, current outlook on life, and acceptance by family/friends than were those whose sessions typically lasted longer than 15 min. Standard counselling sessions typically range from 40 to 50 min, except when client concerns are appropriate for brief counselling approaches. Given the complex issues facing HIV-positive clients, it seems unlikely that such brief sessions provide enough time to go much beyond the psychoeducational aspects of supportive counselling. Therefore, this may be a key area where additional resources are needed to best meet client needs.