HIV-related avoidance and universal precaution in medical settings: opportunities to intervene

Coping efforts made: Psychological burden of people living with tuberculosis due to social stigma in society. A qualitative phenomenology study

The psychological burden is greatly felt by people living with tuberculosis because the characteristics of the disease are very visible and very contagious, and the obligation to take the right dose of medication with long treatment. This is what makes tuberculosis a very stigmatic disease. The aim of this research is to explore the psychological burden felt by people living with tuberculosis due to social stigma by society and how coping efforts are made. This research uses a qualitative phenomenological design through in-depth face-to-face interviews which take place in a semi-structured manner with the hope of obtaining complete data. The purposive sampling method was used in this research with Participatory Interpretative Phenomenology analysis involving 25 participants consisting of 16 men and 9 women. This research produced several themes, including 1) "The Perception of stigma limiting space and time", 2) "The Opportunities for interpersonal interaction become narrow", 3) "The mental stress as a challenging emotion", and 4) " Expanding coping efforts". The psychological burden is felt by people living with tuberculosis because society's treatment is felt to be very discriminatory due to the social stigma that has developed in society so they lose the opportunity to interact with society. For that reason, they tried to explore some of the personal and environmental resources used to modify adaptive coping in resolving perceived psychological burdens. Given the possibility of ongoing stigma and discrimination during tuberculosis treatment programs, it is important to consider the psychological burden in this context, both on the general population and on groups affected by stigma.

Standard Precautions are for everyone: The role of HIV stigma and implications for nursing education in India

Background and objective

Standard Precautions (SP) are infection control procedures universally applicable to every patient. Though SP reduces disease transmission, their implementation is dependent on the knowledge and skills of healthcare workers (HCWs). Poor knowledge regarding the appropriate use of SP can cause fear among HCWs, leading to stigma and discrimination while treating people living with HIV (PLWH). Stigma and discrimination are known barriers for PLWH to access HIV care services. The aim of the study was to assess nursing student knowledge of SP, SP self-efficacy and SP perceived efficacy of nursing students, and (2) to assess the association between SP knowledge, perceived efficacy, and intention to utilize unwarranted precautions, like using double gloves while treating PLWH.

Methods

This paper analyzes baseline (non-randomized) data of a cluster randomized controlled trial amongst 1868 Indian nursing students. Data was collected using computer-administered structured questionnaire. The associations between the measures were done using multiple, logistic and poisson regression models.

Results

Although 97% nursing students could identify SP, only 35.5% understood that they need to be used with all patients. Awareness of the importance of using SP with all patients was positively associated with self-efficacy. Students performing high-risk tasks frequently were significantly more likely to be confident in their ability to correctly use SP, but also had higher intention to use unwarranted precautions.

Conclusions

Existing teaching and training programs for HCWs need to provide clear guidelines and emphasize on the correct use of SP with all patients. This will increase both skills and confidence in their abilities (self-efficacy).

Using bottleneck analysis to examine the implementation of standard precautions in hospitals

BACKGROUND

Service providers are often inadequately compliant with standard precaution protocols. This study used bottleneck analysis to identify the weakest link in standard precaution implementation and its associated challenges in hospitals.

METHODS

Bottleneck analysis was conducted in 12 hospitals in Fujian Province, China. In each hospital, a focus group was organized among the key informants to illustrate the sequential steps of standard precaution implementation graphically. The level of difficulty and the specific challenges associated with each step were discussed.

RESULTS

The sequential activities of standard precaution implementation generally start with making budget for personal protection equipment (PPE), followed by procurement, storage/inventory, in-hospital distribution, in-department distribution, usage/monitoring, and recycling of PPE. Service providers' improper use of PPE was the primary bottleneck. The reasons for improper use of PPE included high workload, time constraints, the sense of wearing PPE would interfere with clinical judgment, and various misconceptions. Making financial planning, recycling, and procurement of PPE were the secondary bottlenecks.

CONCLUSIONS

Bottleneck analysis is useful to illustrate workflow in healthcare systems and pinpoint constraints in standard precaution implementation. Institutional changes, including targeted provider training, adjustment of providers' workloads, and allocation of budget, are suggested strategies to address the identified bottlenecks in standard precaution.

Standard precaution adherence among clinical medical students in HIV and non-HIV ward in Indonesia

INTRODUCTION

Health-care workers, especially medical intern, are at risk of exposed to blood and other body fluids in the course of their work. To reduce the risk, standard precaution (SP) is introduced. Among all communicable diseases that could be transmitted, human immunodeficiency virus (HIV) is the most stigmatized disease. However, there are some government hospitals that separated adult HIV patients with other patients to prevent additional infection. This study aims to evaluate the impact of ward separation on SP adherence.

MATERIALS AND METHODS

This was an observational study conducted in March 2017 in a tertiary referral hospital for the eastern part of Indonesia. The participants were 150 medical students who underwent the past year of their clinical rotation. They were given a three-part questionnaire, consisting of their background, their SP practice in the HIV ward and non-HIV wards, and their perception and attitude regarding SP. McNemar's test and Fisher's exact test were used for the statistical analysis, using SPSS version 23.0 for Windows.

RESULTS

Participants were more adhered to SP (hand hygiene, wear mask as indicated, and wear glove as indicated) in the HIV ward compare to non-HIV wards (P = 0.002, P = 0.001, and P = 0.001, respectively). Almost all participants were more careful in implementing SP in the HIV ward than in non-HIV wards and were more concerned of getting needlestick injury in the HIV ward than in non-HIV ward.

CONCLUSION

HIV and non-HIV ward separation negatively impact medical students' SP adherence.

Standard precaution practice and associated factors among health professionals working in Addis Ababa government hospitals, Ethiopia: a cross-sectional study using multilevel analysis

OBJECTIVES

Occupational exposure to blood and body fluids is a major risk factor for the transmission of infections to health professionals in developing countries like Ethiopia. The aim of this study was to assess standard precaution practices (SPPs) and its associated factors among health professionals working at Addis Ababa government hospitals.

METHODS

A cross-sectional study was conducted on 772 health professionals working at eight government hospitals in Addis Ababa, 2015. The multistage sampling technique was used to select study participants. Health professionals who were directly participating in screening, diagnosis, treatment and follow-ups of patients were studied. SPPs by health professionals were determined by a self-rated response to a 30-item Likert scale. A respondent would be graded as 'good' compliant for the assessment if they scored at least the mean of the total score, or would be considered as poor compliant if they scored less. To take the hierarchical structure of the data into account during analysis, multilevel binary logistic regressions were used. The intraclass correlation coefficient was calculated to evaluate whether variations in score were primarily within or between hospitals.

RESULT

Out of the participants, 50.65% had good SPPs. At the individual level, attitude, age and educational status were found to be important factors of SPPs. Controlling individual-level factors, applying regular observations (adjusted OR (AOR) 1.82; 95% CI 1.2 to 2.76), providing sufficient materials (AOR 1.53; 95% CI 1.03 to 2.28) and weak measures on reported incidences (AOR 0.49; 95% CI 0.30 to 0.8) were also hospital-level factors associated with SPPs.

CONCLUSION

SPPs in the healthcare facilities were found to be so low that both patients and health professionals were at a significant risk for infections. The finding suggests the need for optimising individual-level and hospital-level precautionary practices.

QUESTIONÁRIO DE CONHECIMENTO SOBRE AS PRECAUÇÕES-PADRÃO: ESTUDO DE VALIDAÇÃO PARA UTILIZAÇÃO POR ENFERMEIROS BRASILEIROS

RESUMO Objetivo: validar o Questionário de Conhecimento sobre as Medidas de Precaução Padrão para enfermeiros brasileiros. Método: estudo metodológico, exploratório, realizado em instituições de saúde de dois municípios do interior de São Paulo, realizado com 121 enfermeiros. Os dados foram coletados por meio do questionário sociodemográfico e o questionário de conhecimento sobre as precauções-padrão, adaptado para o português do Brasil, ambos autoaplicáveis. Resultados: o questionário mostrou-se estável e concordante, com Coeficiente de Correlação Intraclasse de 0,91 e índice Kappa satisfatório. A validação por grupos discriminantes não identificou diferença estatisticamente significativa entre os grupos de enfermeiros que informaram ou não ter recebido treinamento sobre medidas de precauções-padrão (p=0,209). Conclusão: a utilização deste questionário pode auxiliar no planejamento e implementações de programas educativos que visem a segurança do paciente e do profissional, tendo como foco a adesão às medidas de precauções-padrão por trabalhadores de saúde.

Reasons and consequences of low adherence to standard precautions by the nursing team

Standard precautions (SP) are recommendations to prevent infection and protect health care workers during the provision of care, however, still exists low adherence to these recommendations. Objective To analyze the reasons and consequences of low adherence to standard precautions by the nursing staff. Method integrative literature review, search in seven databases, from 2005 to 2014. Results 30 articles were selected for analysis. The reasons for low adherence evidenced relate to deficient practices of lifelong learning, risk behaviors of workers, inadequate provision of equipment and protective equipment and inadequate working conditions. The consequences are accidents and occupational diseases. There are few intervention studies, which merely provide guidance to professionals. Conclusions The low adhesion to standard precautions is linked to individual aspects of workers, employers and educational institutions. Intervention strategies carried out have shown little efficient by only focusing on the worker.

Addressing HIV stigma in protected medical settings

Previous studies suggest that the implementation of universal precaution (UP) plays a role in reducing HIV stigma. In this study we investigate the efficacy of a stigma reduction intervention on UP compliance and explore whether UP compliance could potentially influence HIV stigma reduction in medical settings. A randomized controlled intervention trial was conducted in two provinces of China with 1760 healthcare service providers recruited from 40 county-level hospitals. Longitudinal analyses included data collection at baseline, 6-, and 12-month follow-up assessments. Using a hierarchical modeling approach, we estimated the intervention effect for each provider's UP compliance and its potential mediating role on HIV stigma with the bootstrapping method. A significant intervention effect on UP compliance was observed at both the 6- and 12-month follow-up assessments. The intervention effect on provider avoidance intent was partially mediated by the provider's own UP compliance at the two follow-up points. This study provides evidence that UP compliance should be part of HIV stigma reduction programs, especially in resource-restrained countries. Findings suggest that a protected work environment may be necessary but not sufficient to address HIV stigma in medical settings.

Ocorrência de acidentes de trabalho com material biológico potencialmente contaminado em enfermeiros

Objetivo Investigar ocorrência e características dos acidentes com material biológico potencialmente contaminado em enfermeiros.Métodos Estudo transversal que incluiu 121 enfermeiros. O instrumento de pesquisa foi um questionário autoaplicável com variáveis sociodemográficas e relacionadas a acidentes de trabalho.Resultados Em relação à ocorrência de acidente do trabalho com exposição a material biológico potencialmente contaminado entre enfermeiros, 65 (53,8%) foram vítimas. Destes, 63(52,1%) por perfurocortantes e 22 (18,2%) por exposição à mucosa e/ou pele não íntegra. Não houve diferença estatisticamente significativa entre os grupos quanto à ocorrência e notificação do acidente (p=0,791 e p=0,427); conhecimento da resposta vacinal (p=0,379); troca de recipiente de perfurocortantes (p=0,372) e treinamento sobre precauções padrão (p=0,158). Com relação ao treinamento foi verificada diferença estatisticamente significativa (p=0,014) uma vez que enfermeiros nos estabelecimentos menores relataram maior desejo de participação.Conclusão Os acidentes são frequentes entre os enfermeiros e o treinamento relaciona-se positivamente à adesão às precauções-padrão.

Using standardized patients to evaluate hospital-based intervention outcomes

BACKGROUND

The standardized patient approach has proved to be an effective training tool for medical educators. This article explains the process of employing standardized patients in an HIV stigma reduction intervention in healthcare settings in China.

METHODS

The study was conducted in 40 hospitals in two provinces of China. One year after the stigma reduction intervention, standardized patients made unannounced visits to participating hospitals, randomly approached service providers on duty and presented symptoms related to HIV and disclosed HIV-positive test results. After each visit, the standardized patients evaluated their providers' attitudes and behaviours using a structured checklist. Standardized patients also took open-ended observation notes about their experience and the evaluation process.

RESULTS

Seven standardized patients conducted a total of 217 assessments (108 from 20 hospitals in the intervention condition; 109 from 20 hospitals in the control condition). Based on a comparative analysis, the intervention hospitals received a better rating than the control hospitals in terms of general impression and universal precaution compliance as well as a lower score on stigmatizing attitudes and behaviours toward the standardized patients.

CONCLUSION

Standardized patients are a useful supplement to traditional self-report assessments, particularly for measuring intervention outcomes that are sensitive or prone to social desirability.

Implementing a stigma reduction intervention in healthcare settings

Introduction

Globally, HIV-related stigma is prevalent in healthcare settings and is a major barrier to HIV prevention and treatment adherence. Some intervention studies have showed encouraging outcomes, but a gap continues to exist between what is known and what is actually delivered in medical settings to reduce HIV-related stigma.

Methods

This article describes the process of implementing a stigma reduction intervention trial that involved 1760 service providers in 40 hospitals in China. Guided by Diffusion of Innovation theory, the intervention identified and trained about 15–20% providers as popular opinion leaders (POLs) to disseminate stigma reduction messages in each intervention hospital. The intervention also engaged governmental support in the provision of universal precaution supplies to all participating hospitals in the trial. The frequency of message diffusion and reception, perceived improvement in universal precaution practices and reduction in the level of stigma in hospitals were measured at 6- and 12-month follow-up assessments.

Results

Within the intervention hospitals, POL providers reported more frequent discussions with their co-workers regarding universal precaution principles, equal treatment of patients, provider-patient relationships and reducing HIV-related stigma. Service providers in the intervention hospitals reported more desirable intervention outcomes than providers in the control hospitals. Our evaluation revealed that the POL model is compatible with the target population, and that the unique intervention entry point of enhancing universal precaution and occupational safety was the key to improved acceptance by service providers. The involvement of health authorities in supporting occupational safety was an important element for sustainability.

Conclusions

This report focuses on explaining the elements of our intervention rather than its outcomes. Lessons learned from the intervention implementation will enrich the development of future programs that integrate this or other intervention models into routine medical practice, with the aim of reducing HIV-related stigma and improving HIV testing, treatment and care in medical settings.

Instruments for evaluating compliance with infection control practices and factors that affect it: an integrative review

AIMS AND OBJECTIVES

To search for instruments to measure compliance with infection control practices and to report on which dimensions and contents the instruments evaluate, their psychometric characteristics, compliance and factors influencing compliance.

BACKGROUND

Low compliance with infection control practices has been reported among healthcare professionals around the world over the years. Existing data concerning health professionals' compliance with standard precautions are based on measuring instruments.

DESIGN

Integrative review.

METHODS

The descriptors were identified and used separately and in combination to search in the following databases: Lilacs, PubMed (MEDLINE), ISI Web of Knowledge, Scopus and CINAHL. The selected articles complied with inclusion and exclusion criteria.

RESULTS

Twenty-three studies were analysed, resulting in the identification of 18 instruments. No instrument addressed all compliance topics, and the most commonly addressed topics were the use of personal protective equipment, hand hygiene and safe practices in the handling of cutting material. Most authors explored content validity and some performed reliability analysis by means of Cronbach's alpha and test-retest. Countries in the sample have different human development indices, and countries with medium and low human development indices show less compliance. Some variables were strong predictors of compliance: training, perceptions of safe environment, perception of obstacles to comply with standard precautions and knowledge.

CONCLUSIONS

Compliance is below the recommended levels. Health professionals seem to be selective in following standard precautions. Significant influences include institutional management and psychosocial variables, which deserve further study.

RELEVANCE TO CLINICAL PRACTICE

Health managers and government policies and interventions should pay greater attention to this subject.

HIV- and AIDS-Related Stigma: Psychosocial Aspects in a Representative Spanish Sample

This study evaluates the prevalence of HIV stigma in Spain and analyzes some variables that may affect its existence. In 2008, we conducted a computer-assisted telephone survey of 1607 people, representative of the Spanish population. Two-wave random stratified sampling was performed, first selecting the home and then the person, depending on the rates of age and sex. About 50% of the population feels discomfort about potential contact with people with HIV and tries to avoid it and 20% advocate discriminatory policies involving physical or social segregation of people with HIV. The belief that HIV is easily transmitted through social contact (15%) and blaming people with HIV for their disease (19.3%) are associated with stigmatization. Degree of proximity to people with HIV, political ideology, educational level, and age are also associated with the degree of stigmatization. According to these results, we suggest that, in order to reduce stigma, we need to modify the erroneous beliefs about the transmission pathways, decrease attributions of blame to people with HIV, and increase contact with them. These interventions should particularly target older people, people with a low educational level, and people with a more conservative political ideology.

Blood and body fluid exposures in health-care settings: risk reduction practices and postexposure prophylaxis for health-care workers

This review of last year's literature on blood-borne pathogens (= pathogenic microorganisms that are found in human blood) focuses on hepatitis B (HBV), hepatitis C (HCV), and human immunodeficiency virus (HIV) as the most common pathogens, despite the fact that other microorganisms may cause blood-borne diseases as well. Since the prevention of blood-borne diseases is something that, in the past, has gotten a lot of attention and by now is fully integrated in all safety structures in the U.S., the recent literatures mainly have been come from resource-limited/developing countries and Europe (which, in the definition of the financial word at the present time, in some parts overlap).