Appreciative inquiry was used to explore the experiences of HIV practitioners and SLHIV by conducting in-depth individual interviews.

The following components formed part of determining the themes to develop the model:

The population included nine HIV practitioners employed in professional services within a clinical, psychological and HIV practice setting, and 10 SLHIVs who were enrolled in the wellness programme at a university in Gauteng, South Africa. Participants were purposefully selected to participate in the study (Babbie 2017). A total of 19 interviews were held. The student participants’ ages ranged from 19 to 24 years and included four males and six females who were enrolled in the wellness programme for at least 6 months. Practitioners had vast experience dealing with SLHIV, which varied between a maximum of 15 years to a minimum of 3 years. Data saturation was achieved after eight interviews were conducted with practitioners and nine interviews were conducted with SLHIV.

In-depth individual interviews were conducted because of the sensitive and confidential nature of this study. The researchers developed the interview schedule and piloted it to identify potential problems related to the research design and formulation of questions (Gray et al. 2017). Problems with some of the questions were identified and the researchers adapted it. Once ethical clearance was received, the researcher contacted the HIV practitioners in professional services, who were involved in the wellness programme at the university under study. Appointments were scheduled during standard staff meetings to limit disruptions to services. The nature of the study was explained to HIV practitioners and consent forms and participant information sheets were distributed. Interested HIV practitioners were requested to complete the consent forms and to email it to the researcher’s personal email that is password protected.

The researcher scheduled interviews with HIV practitioners who consented, at a time and venue that was suitable to individual practitioners. Human immunodeficiency virus practitioners assisted in the enrolment of prospective student participants for the study. The sampling criteria with the accompanied consent form and participant information sheet were explained to HIV practitioners. Students who were willing to participate in the interviews were required to leave a signed consent form with the HIV practitioner or email the signed consent form to the researcher’s personal email that is password protected. Completed consent forms were collected 1 week later. Participants were contacted and the nature of the study was explained to them. Individual interviews were scheduled at a time and venue suitable for students to ensure confidentiality and minimal disruptions to their studies. A quiet office on campus was used to facilitate audiotaping of interviews. Individual interviews lasted from 45 min to an hour.

The following questions were posed to research participants during individual interviews. See Table 1.

The researcher wrote down feelings and experiences that occurred during the interview process. These personal field notes were taken at the end of each individual interview. This process ensured that the researcher’s personal HIV stories were bracketed before the data analysis happened. Observational notes were based on non-verbal cues detected during the interview process. Descriptive and reflective field notes were compiled during and after each individual interview (Creswell 2013). Methodological notes were written in an attempt to remind the researcher about slight changes for inclusion in the next interview session. Theoretical notes were the researcher’s initial thoughts on the possible themes that could emerge and topics that were later brought into the literature review (Babbie 2017). Appreciative inquiry was employed during interviews by applying the 4-D model (Bushe 2011; Cooperrider 2017; Kessler 2013).

Open coding was used to conduct the data analysis (Creswell 2013). Interviews for HIV practitioners and students living with HIV were transcribed separately and field notes for each were typed. The data were coded by categorising the data and labelling the themes and categories for HIV practitioners and students, respectively, with descriptive terms generated. An independent coder was consulted to verify the themes that were generated (Creswell 2013). A consensus meeting was held between the researchers and the independent coder to reach consensus on the identified themes. Once final agreement on the themes was reached, the researchers arranged a meeting with HIV practitioners who participated in the individual interviews to discuss the themes. A separate meeting was also held with individual student participants who were available. Participants had an opportunity to discuss their impressions of the themes and verify that the themes were a true reflection of the experiences discussed in the individual interviews. A literature control was performed to relate the findings to the current HIV dialogue in the literature (Havenga, Poggenpoel & Myburgh 2014).

The themes and categories identified for students and HIV practitioners, respectively, were finally compared to determine common themes and categories shared between them. The researchers applied inductive reasoning for this process. An independent coder was consulted and consensus was reached. Common themes and categories identified served as the basis for describing and classifying the central concept for the model. Common themes are summarised in Table 2.

The researchers applied inductive reasoning to combine the themes from interviews into a general concept that could be transferable to a broader HIV population. They reflected on the central story and common themes identified during interviews with participants. Through this process, the central statement identified from the findings was facilitation of self-management, and the central concepts were facilitation and self-management. Online dictionaries and subject definitions in the fields of education, nursing and psychology were used to define facilitation and self-management.

By combining the essential and related attributes of the dictionary and subject literature definitions, a final definition was formulated by the researchers. Essential attributes created conceptual meaning for the concepts facilitation and self-management. Table 3 provides a summary of the attributes for the concept self-management as derived from the dictionary and subject literature definitions.

Table 4 provides a summary of the attributes for the concept facilitation as derived from the dictionary and subject literature definitions.

The identified and defined essential attributes of the concepts related to the central concept were used to define facilitation of self-management.

Table 5 summarises the essential attributes for facilitation of self-management.

The final step was to develop a model case to identify what was experienced in the central concept and what the central concept did not reflect. The essential attributes, which form part of the definition of the central concept, were reflected in the model case as described next.

The facilitation of self-management by the HIV practitioner refers to a dynamic interactive process between the psycho-educational facilitator and the SLHIV. This process involves enabling actions by the psycho-educational facilitator that lead to change in the SLHIV. The SLHIV takes control through active participation in partnership with the psycho-educational facilitator to unlock the SLHIVs ability to develop and use cognitive, behavioural and emotional strategies to deal with their infection (Diedricks et al. 2018).

Concepts were classified by means of Dickoff, James and Wiedenbach’s survey list (1968) as illustrated in Figure 2. This survey list assisted in identifying important elements as basis for model development such as agent, recipient, dynamic, procedure, context and terminus:

Relationship statements show the connection between the concepts of the model. It served as the basis for the structure of the model as a frame of reference to facilitate the mental health for SLHIV in a university. Relationship statements were generated between the central concept and the essential attributes (Chinn & Kramer 2015). The following relationship statements illustrate this process (Diedricks et al. 2018):

An overview of the structure and process of the model is described. See Figure 3.

Structure and process of the model: The structure of the model is based on Chinn and Kramer’s concept analysis (2015), specifically referring to the relationship between concepts as illustrated in Step 2: Placing concepts into relationships of this article. The process of the model illustrates the phases that need to be followed in order to attain self-management by the SLHIV. Both the structure and process of the model function interdependently and will be discussed jointly. Figure 3 illustrates the structure and process of the model.

The green upward spiral illustrates the change of the SLHIV from being unable to manage HIV to being able to manage HIV. This green colour depicts the continuity of growth, renewal and restoration (colorpsychology.org 2014). The change is driven by dynamic interactions between the SLHIV and the psycho-educational facilitator, which is illustrated in three distinct phases each relating to actions. The three phases are discussed in the following section.

Context of the model: The orange border represents the counselling room in a university within a wellness programme. The counselling room is a safe space where the facilitation of self-management between the psycho-educational facilitator and the SLHIV occur. The orange colour symbolises warmth and offers emotional strength in difficult times (Diedricks et al. 2018). The orange colour assists in recovery from grief that helps the SLHIV to bounce back from disappointment and despair (colorpsychology.org 2014). The interaction between the psycho-educational facilitator and SLHIV is characterised by the establishment of trust, mutual respect, unconditional acceptance, openness and honesty (Diedricks et al. 2018).

Relationship phase: Phase 1 comprises two arrows moving from the psycho-educational facilitator towards the SLHIV. These arrows illustrate the initial interactive process between the psycho-educational facilitator and the SLHIV. During the initial interactive process the SLHIV is unable to manage his or her HIV and presents with emotional distress, which severely affects the physical, psychological and social aspects of their lives. The dark grey cloud and small grey figure of the SLHIV inside the cloud illustrate the lack of energy displayed by the SLHIV because of the turmoil and emotional distress that the SLHIV is initially experiencing. The psycho-educational facilitator provides a safe and trusting environment for the SLHIVs who take a conscious decision to enter into a partnership with the psycho-educational facilitator towards the facilitation of self-management. The psycho-educational facilitator is dressed in pink, which shows the kind, empathetic and nurturing nature of the facilitator. The facilitator creates a positive environment in order for the dynamic and interactive process to take place between themselves and the SLHIV. The two arrows merge and the dynamic interactive process that entails enabling actions that will lead to change begins. The psycho-educational facilitator’s participation continues as depicted by the green arrow inside the first spiral and the SLHIV’s participation continues as illustrated by the red arrow inside the first spiral. The participation from the psycho-educational facilitator is more compared with the SLHIV as seen by the length of the arrows inside the first spiral.

Working phase: The role of the psycho-educational facilitator is to facilitate active participation and control to unlock the SLHIVs’ ability to self-manage their HIV infection. The psycho-educational facilitator uses psycho-educational techniques to facilitate cognitive, emotional and behavioural strategies to enable change towards an increased ability to self-manage and enhancement of mental health. The SLHIVs actively start to become aware of self-management and start to use it in their daily lives. This increases their ability to control their HIV infection. As the SLHIVs start to use self-management on their own, the psycho-educational facilitator starts to fade out as depicted by the short green arrow on the left hand side inside the second spiral. The working phase represents the largest spiral as most time is spent in this phase. The inside of the spiral is coloured yellow that indicates the clarity of thought, newly acquired knowledge and finding new ways of doing things by the SLHIV, which leads to a sense of self-worth and promote mental health (colorpsychology.org 2014). The facilitation process is flexible and allows for the SLHIV to sometimes move back into a previous phase and then proceed in a forward movement towards self-management again. This relapse process is indicated as small white arrows in the model; it starts outside the termination phase on top and moves downwards towards the working phase. The relapse is a temporary process and is deemed normal considering the complex nature of HIV.

Termination phase: The SLHIV’s ability to self-manage is illustrated by the long red arrow inside the spiral, which occupies most of the space inside the spiral. The termination phase is the smallest spiral in the facilitation process, which illustrates that the SLHIV is able to self-manage their HIV without the guidance of the psycho-educational facilitator. The SLHIVs’ ability to self-manage is further illustrated by the long red arrow inside the spiral, which occupies most of the space inside the spiral. The SLHIV is able to overcome obstacles by using self-management. The skills and knowledge of self-management have been successfully transferred to the SLHIV and they are able to use self-management in the future when they are faced with challenges. The inside of the spiral is shaded lilac, which portrays mental balance and stability (colorpsychology.org 2014) that has been achieved by the SLHIV through the process of self-management. The role of the psycho-educational facilitator minimises as guidance is no longer needed, which is illustrated by the short dotted green arrow. Students living with human immunodeficiency virus have now integrated HIV in all dimensions of their daily lives.

The green colour continues after the termination phase. This depicts the continuity of growth, renewal and restoration (colorpsychology.org 2014) for the SLHIV who is able to self-manage. The colour of the SLHIV changed from dark grey in the initial interactive process of the relationship phase to light blue in the termination phase which illustrates the SLHIV becoming more responsible, confident and able to take control in managing his or her HIV infection (colorpsychology.org 2014). The facilitation process ends in the termination phase. However, the SLHIV continues on the self-management path as indicated by the big golden arrow, which symbolises a higher level of understanding and wisdom (colorpsychology.org 2014) that the SLHIV has acquired in the self-management process. The SLHIV continues with the process of self-management beyond the termination phase, and self-management becomes a way of life for the SLHIV.

Evaluation of the model: The model was evaluated by means of Chin and Kramer’s critical reflection (2015): how simple is this model? how clear is this model for you? how accessible is this model for you? how important is this model? how general is this model? Seven academic panel experts with vast experience in model development participated in the evaluation process. The following feedback was received from panellists (Diedricks et al. 2018):

Guidelines were developed to help the psycho-educational facilitator in a university setting to facilitate self-management of HIV in SLHIV and enhancing their mental health. It is based on the procedure described by Dickoff et al. (1968), which is aligned with the structure and process of the model. Guidelines were designed for the three phases of the model with detailed objectives and related actions to guide the psycho-educational facilitator. The researchers were guided by the six broad stages of self-management as outlined in Rotheram-Borus et al. (2012). These stages are aligned with the journey of change towards self-management of the SLHIV during the working phase. Motivational interviewing (MI) formed the basis for the relationship phase guidelines. Motivational interviewing is a technique that can help the psycho-educational facilitator to enable actions that will lead to change (Elwyn et al. 2014).