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Impact Data - Reducing AIDS-related Stigma and Discrimination in Indian Hospitals

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In 2000, Horizons/Population Council and local governmental and non-governmental organisation (NGO) partners - centrally, SHARAN (an Indian NGO), the Institute of Economic Growth, and India's National AIDS Control Organization (NACO) - undertook a 4-year effort to ensure the provision of non-stigmatising health services to all patients regardless of HIV status. The initiative was a response to evidence such as that from a study conducted in Bangalore and Mumbai, which 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).

Three New Delhi hospitals (one private and two government-run) were selected to take part in the intervention, which focused on "problem solving by partnership" - hospital managers and senior staff together developing action plans to address programme and policy gaps. Each action plan varied by hospital, but, in brief, included: the development and dissemination of printed 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 and drawing on participatory training methods), expansion and strengthening of HIV testing and counselling services, and development and dissemination of educational material (posters) on infection control procedures and post-exposure prophylaxis (PEP).

Methodologies
First, formative research was conducted to understand the causes and manifestations of stigma and discrimination in health care settings. This involved conducting in-depth interviews with health care workers and HIV-positive patients and focus group discussions with PLHA and NGO service providers.

Researchers then used a pre-/post-test evaluation design to assess the outcomes of the pilot programme. A baseline survey was conducted with a random sample of 884 health care workers from 4 departments, representing 3 levels of hospital staff that have contact with PLHA: doctors, nurses, and ward staff. To assess progress, the researchers administered a follow-up survey to a random sample of 885 health care workers and conducted qualitative interviews with hospital managers. As described above, as part of the baseline and endline surveys, a 21-item stigma index was included to examine health care workers' attitudes toward PLHA and discriminatory practices in the health care setting.
Knowledge Shifts
Overall, there were large increases in knowledge, especially among ward staff. For example, there was a significant increase (p < .05) in the number of ward staff who reported that HIV cannot be transmitted by touching someone with HIV/AIDS (80% vs. 96%), by sharing utensils (67% vs. 83%), by sharing clothes (63% vs. 86%), or by coming close to someone with HIV/AIDS (81% vs. 98%). Health workers reported improved understanding and practice of universal precautions and infection control procedures (e.g., using gloves whenever drawing blood or starting an IV on a patient). Hospital managers corroborated positive changes in knowledge.

"Despite improvements, some misinformation persists, particularly among ward staff. For example, at endline, only 35 percent of ward staff believed that HIV is not transmitted by mosquitoes and 51 percent that it is not transmitted through sputum."
Practices
"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."

At endline, more doctors reported wearing gloves for at-risk procedures such as drawing blood (64% vs. 93%; p < .05), as did ward staff for procedures such as carrying patients' blood samples (29% vs. 93%; p < .05). Doctors were also more likely to seek informed consent the last time they ordered an HIV test (59% vs. 40%).

At baseline, health care workers often took it upon themselves to inform peers and other staff in the hospital about a patient's HIV-positive status. At follow-up there was some improvement among doctors, as a smaller proportion reported informing nurses (87% vs. 71%) and ward staff (51% vs. 30%) about a patient's serostatus. Nurses corroborated this trend; compared to baseline, a smaller proportion at follow-up reported being informed by doctors of a patient's positive HIV status (31% vs. 17%). But there was essentially no change among nurses in telling ward staff (97% vs. 99%). In short, "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."
Attitudes
The study found improvements in health workers' attitudes toward PLHA 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 behaviour; another asked whether patients with HIV should be kept at a distance from other patients. Overall, the proportion of health workers who were categorised as being the least stigmatising more than doubled after the intervention (from 12% to 27%), and the proportion of respondents in the most stigmatising category declined considerably (from 24% to 7%).

Here are a few examples of findings on specific measures from the stigma index: Fewer nurses and ward staff agreed that there was a need to take excessive steps such as disposing of or burning linens used by HIV-positive patients (67% vs. 54%; p < .05). Following the intervention, doctors were more likely to agree that patients should not be tested without their consent (67% vs. 37%). A greater proportion of doctors (74% vs. 85%; p < .05) and nurses (89% vs. 92%) said that HIV-positive individuals have the right to decide who should know their status, but this was not the case among ward staff (73% vs. 66%).
Other Impacts
The successful 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. In addition, the intervention tools are being adapted for other countries' use.
Source
"Reducing Stigma and Discrimination: Indian Study Finds Improved Attitudes and Practices among Hospital Workers", Horizon Report, June 2006 - sent by Alison Lee of Horizons to The Communication Initiative on August 1 2006 (This article is available by contacting Sherry Hutchinson at the above address.); Reducing AIDS-related Stigma and Discrimination in Indian Hospitals [PDF], by Vaishali S. Mahendra, Laelia Gilborn, Bitra George, Luke Samson, Rupa Mudoi, Sarita Jadav, Indrani Gupta, Shalini Bharat, and Celine Daly, Horizons Final Report; and email from Sherry Hutchinson to The Communication Initiative on August 4 2010.