An Overview: Stigma and health care providers
HIV stigma can operationally defined as that invisible but strongly felt mark given to a person that makes him or her feel different than others. Many focus group discussions with patients and carers reveal that that the hospital was a key place where stigma was first felt or been sustained. The way an HIV suspicion or diagnosis was made, left a feeling of being different, of being looked down upon, inferior, or ignored. Examples we have heard or witnessed include:
- Inability to break the news at the bedside, the euphemisms used for HIV/AIDS among the clinical staff: “immuno-compromised”, “the RVtest came back”, all meant to “protect” the patient from bad news which in fact the staff cannot handle, resulting in news being spread as fire among all staff except the patient: the conspiracy of silence
- Immediate discharge after lab result is known to clinician or withholding a lab result until discharge, with the argument that very little can be done in the hospital and that it is better to see a community or home care program. Where, how, when and why is hardly addressed , giving the patient and family the feeling of being neglected (“dumping care”).
- Being provided with a different kind of care or lack of care, feeling ignored and less respected than other patients.
- Refusal to be admitted, in many hospitals in various countries up till today is still a major issue where stigma is bluntly being translated in immediate discriminatory action, again by marking a patient in such a way that even rights to emergency health care are being denied.
Such examples have also been seen with other diseases or conditions: TB, leprosy, physical disabilities, mental illnesses, and cancer. However in these instances effective therapies, social and psychological support have reduced stigma to a certain extent.
Attitudes and lack of knowledge and skills have been suggested as determinants of stigma in the health setting but are still poorly understood. Hence we have this discussion to get your views on the why, the areas for further study and the possible solutions.
The following factors could explain part of these attitudes and beliefs
among health staff:
- A judgmental reaction to what is perceived by many societies as taboos: sex in the sense of socially disapproved sexual relations and death, two aspects of life many people are often silent about, even more so when these two are linked as it is felt about HIV/AIDS.
- Personal fears of getting infected in the working environment usually expressed by health staff as the major reason for potentially stigmatizing actions, but often exaggerated and not always rational.
- Perceived fears of not being able to handle a patient’s emotional reaction to a diagnosis, often reflect the carers attitude and skills towards psychosocial care.
- Personal fear of one own’s serostatus as a health care staff functioning as a defense mechanism and creating distance between carer and patient . This fear is being aggravated in the absence of VCT services for health care workers. Very few counselors, nurses, doctors, or Ministry of Health staff know their own serostatus.
- Helplessness as a result of lack of counseling skills, lack of time or lack of treatment. Lack of drugs, in particular antiretrovirals are often used as an excuse for the conditions to allow stigma in the health care setting but there are now plenty of examples where HIV care providers have shown that with giving a bit of time and empathy, involving others who do have counseling skills, early and proper management and preventive therapy of opportunistic infections, good social support, good nursing care, good home care and above all good coordination between all these care activities, quality of life and survival benefits can be achieved at low cost.
An obvious result of stigma in the health care setting is silence, in fact a conspiracy of silence as all partners in silence know but don’t say. Somehow it has a protective effect for a patient initially as it gives time to cope with this unjust environment and allows privacy but eventually the silence will only aggravate the suspicion by many others and results in acts of discrimination. The silence becomes secrecy resulting in gossiping and the unspoken marking i.e. stigma occurs.
What are then potential ways to address, fight and reduce stigma:
-At the level of the care provider: openness while maintaining the confidentiality for an individual patient. That sounds as a contradiction but it’s not. An environment like a clinic or hospital can normalize HIV as a day to day business to be openly discussed in staff meetings, health education, public meetings etc showing as an example to provide patient friendly care and as well having peer doctors and nurses as models to juniors how to provide care with dignity, very important in such an hierarchical establishment as a hospital, while at the same time maintaining the needed confidentiality at the individual level through establishing counseling services and giving the feeling of patients of being supported and being left alone. Small things do wonders: body language, an ear to listen, a touch or a small effort extra.
-At the level of the client or patient: discussing at an early stage in the counseling process the options for sharing and disclosure, whenever a client is ready and involving that significant other identified by the client. Formation of groups of patients with chronic illnesses for social and educative events and involvement in planning the care need. Examples from TB wards and HIV support groups within hospitals in Thailand, Uganda.
-At the level of the hospital management: normalization of HIV, taking counseling serious, and providing staff time, space and support to implement services. Ensuring that breaking the news of a laboratory diagnosis is done in the context of counseling pre- and post-test and time to follow up. But also promoting all health staff to know their serostatus and facilitating an anonymous service including follow up care support for infected staff. Feelings of safety can be improved by setting standards to adhere to universal precautions and follow up through infectious disease management committees and provision of post exposure prophylaxis for accidental prick incidents.
-At the level of the community and family: informing and discussing again and again, stimulating care activities to be taken up by communities themselves, addressing prevention and care always together as that will help to normalize HIV/AIDS.
I am sure there are many more practical examples of how we can address stigma in the health care setting and as well many more thoughts on the determinants underlying stigma, hence this call for reactions, responses and ideas.
No doubt certain elements need to be better studied and we call on you for ideas for such an intervention-linked research and topics of research geared to better understanding
Dr Eric van Praag
Email: evanpraag@fhi.org
(Source: Stigma-AIDS eforum, April 2001. To join email Join-stigma-aids@eforums.healthdev.org)
- Inability to break the news at the bedside, the euphemisms used for HIV/AIDS among the clinical staff: “immuno-compromised”, “the RVtest came back”, all meant to “protect” the patient from bad news which in fact the staff cannot handle, resulting in news being spread as fire among all staff except the patient: the conspiracy of silence
- Immediate discharge after lab result is known to clinician or withholding a lab result until discharge, with the argument that very little can be done in the hospital and that it is better to see a community or home care program. Where, how, when and why is hardly addressed , giving the patient and family the feeling of being neglected (“dumping care”).
- Being provided with a different kind of care or lack of care, feeling ignored and less respected than other patients.
- Refusal to be admitted, in many hospitals in various countries up till today is still a major issue where stigma is bluntly being translated in immediate discriminatory action, again by marking a patient in such a way that even rights to emergency health care are being denied.
Such examples have also been seen with other diseases or conditions: TB, leprosy, physical disabilities, mental illnesses, and cancer. However in these instances effective therapies, social and psychological support have reduced stigma to a certain extent.
Attitudes and lack of knowledge and skills have been suggested as determinants of stigma in the health setting but are still poorly understood. Hence we have this discussion to get your views on the why, the areas for further study and the possible solutions.
The following factors could explain part of these attitudes and beliefs
among health staff:
- A judgmental reaction to what is perceived by many societies as taboos: sex in the sense of socially disapproved sexual relations and death, two aspects of life many people are often silent about, even more so when these two are linked as it is felt about HIV/AIDS.
- Personal fears of getting infected in the working environment usually expressed by health staff as the major reason for potentially stigmatizing actions, but often exaggerated and not always rational.
- Perceived fears of not being able to handle a patient’s emotional reaction to a diagnosis, often reflect the carers attitude and skills towards psychosocial care.
- Personal fear of one own’s serostatus as a health care staff functioning as a defense mechanism and creating distance between carer and patient . This fear is being aggravated in the absence of VCT services for health care workers. Very few counselors, nurses, doctors, or Ministry of Health staff know their own serostatus.
- Helplessness as a result of lack of counseling skills, lack of time or lack of treatment. Lack of drugs, in particular antiretrovirals are often used as an excuse for the conditions to allow stigma in the health care setting but there are now plenty of examples where HIV care providers have shown that with giving a bit of time and empathy, involving others who do have counseling skills, early and proper management and preventive therapy of opportunistic infections, good social support, good nursing care, good home care and above all good coordination between all these care activities, quality of life and survival benefits can be achieved at low cost.
An obvious result of stigma in the health care setting is silence, in fact a conspiracy of silence as all partners in silence know but don’t say. Somehow it has a protective effect for a patient initially as it gives time to cope with this unjust environment and allows privacy but eventually the silence will only aggravate the suspicion by many others and results in acts of discrimination. The silence becomes secrecy resulting in gossiping and the unspoken marking i.e. stigma occurs.
What are then potential ways to address, fight and reduce stigma:
-At the level of the care provider: openness while maintaining the confidentiality for an individual patient. That sounds as a contradiction but it’s not. An environment like a clinic or hospital can normalize HIV as a day to day business to be openly discussed in staff meetings, health education, public meetings etc showing as an example to provide patient friendly care and as well having peer doctors and nurses as models to juniors how to provide care with dignity, very important in such an hierarchical establishment as a hospital, while at the same time maintaining the needed confidentiality at the individual level through establishing counseling services and giving the feeling of patients of being supported and being left alone. Small things do wonders: body language, an ear to listen, a touch or a small effort extra.
-At the level of the client or patient: discussing at an early stage in the counseling process the options for sharing and disclosure, whenever a client is ready and involving that significant other identified by the client. Formation of groups of patients with chronic illnesses for social and educative events and involvement in planning the care need. Examples from TB wards and HIV support groups within hospitals in Thailand, Uganda.
-At the level of the hospital management: normalization of HIV, taking counseling serious, and providing staff time, space and support to implement services. Ensuring that breaking the news of a laboratory diagnosis is done in the context of counseling pre- and post-test and time to follow up. But also promoting all health staff to know their serostatus and facilitating an anonymous service including follow up care support for infected staff. Feelings of safety can be improved by setting standards to adhere to universal precautions and follow up through infectious disease management committees and provision of post exposure prophylaxis for accidental prick incidents.
-At the level of the community and family: informing and discussing again and again, stimulating care activities to be taken up by communities themselves, addressing prevention and care always together as that will help to normalize HIV/AIDS.
I am sure there are many more practical examples of how we can address stigma in the health care setting and as well many more thoughts on the determinants underlying stigma, hence this call for reactions, responses and ideas.
No doubt certain elements need to be better studied and we call on you for ideas for such an intervention-linked research and topics of research geared to better understanding
Dr Eric van Praag
Email: evanpraag@fhi.org
(Source: Stigma-AIDS eforum, April 2001. To join email Join-stigma-aids@eforums.healthdev.org)
posted by AIDS-Care-Watch at 11:28 am
0 Comments:
Post a Comment
<< Home