Horizons Report | June 2006 | Reducing Stigma and Discrimination

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June 2006

Reducing Stigma and Discrimination
Indian study finds improved attitudes and practices among hospital workers

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Three doctors are standing around a male patient sitting on a bed. The patient has a female visitor.

Indian hospital workers aim to ensure the provision of non-stigmatizing health services to all patients regardless of HIV status.

Photo credit: Population Council

For people living with HIV, stigma and discrimination can extend into the hospital setting, where it can lead to the denial of care, differential treatment, and disregard for the right to patient confidentiality. Fear of such treatment may cause many people living with HIV to avoid seeking critical health care.

Such is the case in India where AIDS-related stigma and discrimination among health workers in the hospital setting has been documented. For example, a study conducted in Bangalore and Mumbai found that many health providers denied care to HIV-infected patients, labeled admitted patients as HIV-positive, disclosed their HIV status to family members and others without their permission, and excessively used barrier precautions when working with them (UNAIDS 2001).

Recognizing the need to move beyond documentation of the problem, Horizons, SHARAN (an Indian NGO), and the Institute of Economic Growth collaborated with India’s National AIDS Control Organization (NACO) and three New Delhi hospitals to design and assess responses to hospital-based stigma and discrimination. This comprehensive study, conducted from 2000–2004, found that tailored interventions to protect the well being of both patients with HIV and health workers contributed to a safer and less stigmatizing and discriminatory hospital environment.

Problem Solving by Partnership

Central to the design of each hospital’s response to the problem of AIDS-related stigma and discrimination was the use of a self-assessment checklist (Box 1). This tool identifies institutional strengths and weaknesses of services for people living with HIV, and of policies and procedures to prevent occupational exposure to HIV by staff.

Box 1 The PLHA-friendly Checklist

This self-assessment tool identifies how well health facilities serve HIV-positive people and provide a safe working environment for staff. The checklist items are organized according to five key domains:

Access to services
HIV testing and counseling
Confidentiality
Infection control
Quality of care

Hospital records, survey data, observations, or simply “guesstimates” can be used to rate an institution. To view the complete checklist, go to http://www.popcouncil.org/horizons/pfechklst.html or consult the study’s final report on the Horizons Web site.

During initial meetings with hospital managers and senior staff, the project team discussed findings from baseline research conducted in the study hospitals. These findings focused on the causes and manifestations of stigma and discrimination, and HIV-related attitudes, knowledge, and practices of health workers.

After discussing the findings, hospital managers and senior staff used the checklist to assess the extent to which their facilities followed gold standards to ensure AIDS-related staff safety and a non-stigmatizing and non-discriminatory hospital environment.

Based on the assessment, hospital managers and senior staff developed action plans to address program and policy gaps. Each action plan varied by hospital but included the development and dissemination of guidelines for HIV care and management, sensitivity training of health workers about the needs and rights of people with HIV (led by local AIDS NGOs), expansion and strengthening of HIV testing and counseling services, and development and dissemination of educational material on infection control procedures and post-exposure prophylaxis (PEP) availability for staff.

“We found that a problem-solving, partnership approach allowed us to work successfully with hospital staff and motivate them to take action to improve the hospital environment,” stated Vaishali Mahendra of Horizons/Population Council, one of the study’s principal investigators.

She explained that when the study began, hospital managers feared that data about discrimination would be used for lawsuits and negative publicity, and AIDS NGOs tended to blame health workers for stigmatizing or discriminatory practices. “We assured the hospitals that the data would be confidential and not reported by hospital, and sensitized NGO staff about the concerns and difficulties of health workers who practice in resource-constrained settings,” Ms. Mahendra added.

Improved Knowledge and Attitudes

To determine the effects of the action plan interventions on hospital worker’s knowledge, attitudes, and practices, the researchers compared baseline and follow-up survey data from more than 800 respondents and conducted follow-up interviews with managers and senior staff.

Overall there were large increases in the understanding of HIV transmission by health workers. For example, there was a significant increase in the number of ward staff who reported that HIV cannot be transmitted by touching someone with HIV or AIDS (from 81 percent to 96 percent).

Hospital managers corroborated positive changes in knowledge and explained how they translated into improved practices. As a doctor and department head reported:

About three or four years back, we had an HIV-positive patient…. The ward staff sprayed DDT [a pesticide] all around the patient’s bed so that the virus would not spread. Now these things do not happen.

The study also found improvements in health workers’ attitudes toward people living with HIV and less support for discriminatory hospital practices. To measure these domains, the researchers developed a 21-item stigma index, which was incorporated into the baseline and follow-up surveys. One of the questions asked whether the respondents agreed or disagreed that HIV spreads due to immoral behavior. Another asked whether patients with HIV should be kept at a distance from other patients.

The researchers analyzed respondents’ scores on the stigma index by dividing them into three categories: low stigma, medium stigma, and high stigma. Overall, the proportion of health workers who were categorized as being the least stigmatizing more than doubled after the intervention (from 12 percent to 27 percent). At the same time, the proportion of respondents in the most stigmatizing category declined considerably (from 24 percent to 7 percent).

An older woman and a gentleman sit on the bed beside a female patient.

Informed consent for HIV testing and the right to patient confidentiality are hallmarks of the hospital intervention in India.

Photo credit: Population Council

HIV Testing and Confidentiality

Health workers reported some improvement in their attitudes and practices regarding informed consent and confidentiality. For example, following the interventions, doctors were more likely to agree that patients should not be tested without their consent (67 percent vs. 37 percent). They were also more likely to seek informed consent the last time they ordered an HIV test (59 percent vs. 40 percent).

Although after the intervention a greater proportion of doctors and nurses said that HIV-positive individuals have the right to decide who should know their serostatus, among ward staff the number who agreed actually declined. Fewer doctors reported informing nurses of patients’ positive HIV status, and nurses corroborated this finding. At the same time, this change was not true of nurses, who said they continued to inform ward staff of patients’ status.

Better Infection Control

Health workers reported improved understanding and practice of universal precautions and infection control procedures. This includes using gloves whenever drawing blood or starting an IV on a patient. In addition, fewer nurses and ward staff agreed that there was a need to take excessive measures such as burning linens used by HIV-positive patients. The improvements in the use of universal precautions may reflect the fact that fewer health care workers reported shortages of gloves and other supplies following the intervention. Also, more stated that they had access to PEP.

Recommendations

Findings from this research suggest that the actions taken, including education, training, policy formulation, and involvement of AIDS NGOs, contributed to improved knowledge, attitudes, and practices among health workers. However, although the survey data show significant improvements related to the care and management of people living with HIV, which were corroborated by interviews with hospital managers, there is room for refining the intervention. For example, many health care workers continued to feel that they were entitled to know the HIV status of their patients and to share this information with one another even as they expressed increased respect for patient privacy in general. More work is therefore needed to translate changes in attitudes to changes in practices.

Since all cadres of health care workers carry out discriminatory practices, it is critical to involve everyone, from ward staff to hospital superintendents. This includes involvement in initial and refreshing training that provides information on HIV and sensitizes staff to the needs, concerns, and rights of HIV-positive patients. At the same time, these efforts must be accompanied by policies, information, and supplies that create a safe working environment for health workers.

The results of the study encouraged the collaborating hospitals in New Delhi to scale up the intervention hospital-wide to all departments and staff. NACO endorsed the use of the checklist in all public hospitals and disseminated it to all the State AIDS Control Societies in the country. The study has received worldwide attention as one of the few hospital-based interventions to counter stigma and discrimination, including endorsement from UNAIDS and the International Council of Nurses. In addition, the intervention tools are being adapted for other countries’ use.

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See Also

For additional information please contact:
Horizons
Population Council
4301 Connecticut Ave. NW, Suite 280
Washington, DC 20008
Telephone: +1 202 237 9400
Facsimile: +1 202 237 8410
E-mail: horizons@popcouncil.org

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This page updated
21 July 2006