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Abstract Background Healthcare workers (HCWs) in South Africa widely use job-aids as practical tools to enhance the provision of HIV services, thereby improving patient-provider interactions during the care process. Job-aids are visual support materials that provide appropriate information using graphics and words in a simple and yet effective manner. We explored the mechanism through the KidzAlive Talk tool storybook (Talk tool), a child-centred job-aid for HCWs that facilitates child-participation during HIV consultations in primary healthcare (PHC) clinics implementing the KidzAlive model. Methods The study was conducted in PHC clinics across four districts; namely: uMkhanyakude, Zululand, uMgungundlovu, and eThekwini in KwaZulu-Natal (KZN), South Africa. We conducted in-depth interviews with children (n = 30), their primary caregivers (PCGs) (n = 30), and KidzAlive trained and mentored HCWs (n = 20). Data were collected in both English and isiZulu languages through user-specific, structured in-depth interviews. All the interviews were audio-recorded (with participants’ assent and consent, respectively). Data were transcribed verbatim, prior to translating the isiZulu transcripts to English. Translations were done by a member of the research team competent in both languages. Electronic data were imported to NVivo 10 for analysis and subsequently analysed using a thematic analysis method followed by a constant comparative and modified grounded theory analysis method. Results The findings identified the following barriers to child-participation: Primary caregiver limiting the child’s involvement due to fear of traumatising them; HCWs’ limited knowledge and skills to deliver child-centred HIV care; childhood developmental stage-related limitations and healthcare institutional paternalism. The Talk tool addresses the above barriers by using simple language and terminology to cater for children at various stages of development; alleviating HCWs’ and PCGs’ fear of possible psychological harm to the child; using storytelling and colourful cartoon illustrations for child edutainment; Being versatile by allowing for multiple utility and tackling institutional paternalism that limit child-involvement in the process of care. Conclusions This study provided evidence on how the Talk tool storybook addresses barriers to child-participation in the HIV care process. The evidence generated from this study is compelling enough to recommend the scale-up of this innovation in low-resource settings.

Abstract Background KidzAlive is a child-centred intervention aimed at improving the quality of HIV care for children in South Africa. Through this intervention, 10 child-friendly spaces were created in 10 primary healthcare centres (PHCs) in KwaZulu-Natal to enhance child-centred HIV care. However, the user-provider experiences of these child-friendly spaces in these facilities have not been explored. This paper addresses this gap. Methods We conducted qualitative interviews with children (n = 30), their primary caregivers (PCGs) (n = 30), and KidzAlive trained healthcare workers (HCWs) (n = 20) using and providing child-friendly spaces, respectively. Data were generated, using a semi-structured interview guide printed in both English and IsiZulu. The interviews were audio-recorded transcribed and translated to English by a research team member competent in both languages. Data were imported to NVivo 10 for thematic analysis. The COREQ checklist was used to ensure that the study adheres to quality standards for reporting qualitative research. Results Child-friendly spaces contributed to the centredness of care for children in PHCs. This was evidenced by the increased involvement and participation of children, increased PCGs’ participation in the care of their children and a positive transformation of the PHC to a therapeutic environment for children. Several barriers impeding the success of child-friendly spaces were reported including space challenges; clashing health facility priorities; inadequate management support; inadequate training on how to maximise the child-friendly spaces and lastly the inappropriateness of existing child-friendly spaces for much older children. Conclusion Child-friendly spaces promote HIV positive children’s right to participation and agency in accessing care. However, more rigorous quantitative evaluation is required to determine their impact on children’s HIV-related health outcomes.