Stigmatizacija i diskriminacija HIV pozitivnih osoba i osoba oboljelih od AIDS-a u zdravstvenom sustavu Federacije Bosne i Hercegovine: gledišta zdravstvenih djelatnika i pacijenata

Vučina, Iskra. (2018). Stigmatizacija i diskriminacija HIV pozitivnih osoba i osoba oboljelih od AIDS-a u zdravstvenom sustavu Federacije Bosne i Hercegovine: gledišta zdravstvenih djelatnika i pacijenata. Specialist Thesis. Filozofski fakultet u Zagrebu, Department of Psychology.
(Poslijediplomski specijalistički studij kliničke psihologije) [mentor Kuterovac Jagodić, Gordana].

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Abstract

The research is a sort of follow-up research from 2011 on HIV/AIDS stigma and discrimination in the health sector of the Federation of Bosnia and Herzegovina which was also conducted by the Institute for Public Health of the Federation of Bosnia and Herzegovina. This research in 2014 was conducted in 10 cities, within 17 health institutions, which included a total of 1.164 health workers from all three levels of healthcare, together with 48 people living with HIV in the Federation of Bosnia and Herzegovina. We examined the attitudes and experiences of health workers regarding to HIV, HIV/AIDS education and knowledge, attitudes and practices about HIV with an emphasis on HIV stigma and discrimination. Along with health workers, people living with HIV were asked about living with HIV/AIDS, detection of HIV positive status and experience of stigmatization and discrimination in the health sector. Stigma profoundly affects the lives of people living with HIV/AIDS, as well as the lives of those who are at risk of becoming infected with HIV. Fear of being identified as person with HIV/AIDS may discourage a person from getting tested, accessing medical services, and disclosing their HIV status to family and friends. It is believed that medical workers’ understanding for the daily struggle of people living with HIV is vital for health and survival of people living with HIV, in the same way as it is understanding and acceptance of family members. Aim General aim of the study is to examine the existence of HIV/ AIDS-related stigma and discrimination among health workers in the health sector of the Federation of Bosnia and Herzegovina. Problems and hypothesis of the research 1. Examine the experiences, behavior and knowledge of health workers in FBiH in relation to HIV and AIDS and those living with these diagnoses. H1: It is assumed that health workers will have good basic knowledge about the disease and ways of spreading it, and that their experiences and behaviors will be neutral or positive to patients living with HIV/AIDS. Specifically, younger health professionals, health professionals with university degree and those from higher health care level are expected to have more knowledge of HIV/AIDS and neutral or positive behaviors from older workers and those working in institutions from lower levels of health care protection and without university degree. 2. To examine the presence of stigmatizing attitudes and perceived discrimination of people living with HIV/AIDS among health workers and determine whether it varies depending on age, gender, educational profile and health care level. H2: It is assumed that certain, but small or moderate, representation of stigmatization and discrimination of persons with HIV/AIDS will be determined by health workers. Specifically, younger health workers, women and healthcare professionals with higher education levels and higher levels of health care are expected to have less stigmatizing attitudes and discriminatory behaviors than older workers, men, lower educated workers, and lower-level health care workers. 3. Examine the stigmatizing and discriminatory experiences in the health sector in the FBiH of people living with HIV/AIDS. H3: It is expected that people living with HIV/AIDS will report on a small or moderate number of discrimination experiences and that male participants will report on a greater degree of stigmatization and discrimination in compare to women participants. Methodology The study was conducted as a cross-sectional study on a randomly selected sample of health workers and people living with HIV/AIDS. Sample The research covers health workers employed in public health institutions of primary, secondary and tertiary levels. For the purposes of the research, stratified multi-stage cluster sample in four levels has been chosen: Level I - health institution’s four strata determination, level II - 4 strata of health workers (medical doctors, dentists, medical technicians/nurses and laboratory technicians), III level - selection of participants or clusters depending on the number of health institutions and level IV - health workers accidentally present at the time of research till completion of the required number. The sample has been determined by random stratification principle. The strata were determined according to the regional distribution of health institutions, which will ensure geographical coverage of the entire territory of the Federation of Bosnia and Herzegovina. The sample frame has been made based on the data of regular health statistics of the Institute of Public Health of the FB&H. Out of a total of 1.164 participants, 783 (67.3%) were women and 309 (26.6%) males, and 72 (6.2%) did not answer on this question. Accordingly at what level of health care were employed, 375 (32.2%) were employed in health centers, 375 (32.2%) came from general and cantonal hospitals, 39 (3.4%) from the Institute for Transfusion Medicine, and from clinical centers 375 (32.2%). When it comes to occupation, in this research participated 747 nurses / technicians (64.2%), 306 medical doctors (26.3%), 87 laboratory technicians (7.5%) and 24 dentists (2.1%). Along with health workers, the sample includes people living with HIV/AIDS who use DPST centers’ health services. In the survey participated 48 people living with HIV / AIDS. On the question about sex, 20 of them did not answer, while from the remaining 28 participants 21 (75%) were male and 7 (25%) female. Approximately half of the participants (46.4%) belong to the age group of 31-40 years. The next most frequent group is those aged 41 to 50 (25%) and then older than 50 (21.4%). The lowest percentage of participants (7.1%) belongs to the age group younger than 30 years. As far as work status is concerned, 45.7% of respondents are employed, of which 51.4% are men and 22.2% of women. Study instruments A questionnaire, especially made for this study and based on similar studies in the region and the world, was used as a study instrument. The questionnaire was adapted to the situation and needs in the Federation. The questionnaire contains questions from the following areas: health workers’ views and experience related to HIV, health workers’ education about HIV/AIDS, HIV-related knowledge, attitudes and practice, with the emphasis on stigma and discrimination, as well as some general sociodemographic characteristics of the participants. A questionnaire for the people living with HIV was also based on the questionnaires with the same topic from the world and the region. The questionnaire contains questions about living with HIV/AIDS, detection of HIV-positive status, experience of stigma and discrimination in the health sector and socio-demographic characteristics of people living with HIV/AIDS. Organization of the research The Institute for Public Health FB&H with its research team was in charge of conducting this research. Field work coordinators and study administrators are persons appointed from the PHI of the FB&H. Before the field work started, health institutions that took part in the study were informed in written about the aim and method of the study and they gave written consent for its implementation. Directors of health institutions appointed associates for conducting the study, who organized participant surveys with the study administrators, at the arranged time and place. Distribution of questionnaires to people living with HIV/AIDS conducted advisors from DPST centers in person. Participation of health institutions, health workers and people living with HIV/AIDS in the study was voluntary. As the questionnaire did not have any personal information, and as the participants filled in the questionnaires by themselves and returned them in sealed, unmarked envelopes, the anonymity of the participants in the study was ensured in that way. The questionnaires which were filled in and put in envelopes, were delivered to the research team by study administrators. The research was conducted with full respect for the principles of Declaration of Helsinki. Given the delicacy of the research topic, all documents collected by the main research team members were submitted for review and approval to the Ethics Committee of the Institute for Public Health FB&H. After obtaining the written consent of the Committee on the proposal and implementation of research, the field work has been carried out. Statistical data analysis With the aim to describe the sample and subsample, frequencies, percentages, arithmetic means, standard deviations and standard errors were calculated. The importance of the differences among subsamples, i.e. different categories of participants, was calculated with Student’s t-test and Fisher variance analysis when the variables measured on bar interval level are in question, ie. with Pearson’s chi-squared test (with Yates’ correction in case of a need) when nominal variables are in question. To determine the underlying structure in the basis of the answers, Maximum-Likelihood factor analysis was used. Results Health workers The largest percentage of health workers working in tertiary level of health care confirmed to have had contact with people living with HIV/AIDS (49.3%), while that percentage is the least in secondary level of health care (17.7%). The most often medical interventions in which health workers are in contact with patient’s blood or other body fluids are bandaging up wounds 62.1% and administration of parenteral therapy 56.4%, and those the least often are delivering babies 8.8%. 66,9% of the health workers who participated in the study answered they would apply additional precautionary measures if they knew/thought that a patient was HIV positive. Almost a half of the participants answered they would feel nervous if they knew their patient is an HIV-positive person (44.5%), 13.5% of them would feel very nervous, while 35.1% of them would not feel nervous in contact with an HIV-positive person. 49.8% of health workers participating in this study would without feeling uneasy provide medical service to a patient living with HIV, while 10% of them would not do so. According to the opinion of the participants, fear of getting infected despite the high awareness and knowledge in 30% of cases may influence health worker’s decision to refuse to provide service to an HIV-positive patient. 91.6% of the participants answered that even a single unprotected sexual intercourse with a person living with HIV can lead to HIV infection, while only 2.4% answered negatively. The highest percentage of the participants named blood (97.9%), semen (88.0%), vaginal secretion (81.9%), and breast milk (51.1%) as a means of transmitting HIV. 38.9% of the participants believe that HIV-positive health workers should be allowed to work with patients, while 35.5% of the participants believe that they should not be allowed to work with patients. 63,1% of the participants believe that patients should be tested on HIV without their consent before an operation or other intervention. Only 17.9% of the participants are against that. Vast majority of the participants would work with their colleague if they found out he/she is HIV-positive (72.4%). Slightly less than a half of the participants believe that women living with HIV should not get pregnant (45.0%) while 21.3% of them disagree. Almost the three-fourths (73.5%) of the participants do not believe AIDS might be punishment from God. 39.1% of the participants believe that a person living with HIV has the right to self-determine who should know about it, 23.1% are not sure and 37.8% disagree. Discrimination within health institutions to which the participants witnessed was evaluated based on several statements. 11.3% confirmed that patient living with HIV received less attention than other patients. 57.8% participants confirmed that additional preventive measures were taken for sterilizing instruments used for treating patients living with HIV/AIDS. 17.3% of the participants confirmed that patient was unnecessarily referred to another doctor by a health worker since he/she was HIV-positive, while almost a half of the participants (45.5%) confirmed that latex gloves were used for noninvasive examination of a patient suspected of being diagnosed with HIV. About one-fourth of the participants (25.3%) confirmed that health worker revealed patient’s HIV status. Regarding discrimination according to the level of healthcare, if we observe the mean value, a statistically significant difference between the secondary and tertiary level of healthcare can be found. The biggest discrimination is found in tertiary level and the lowest in secondary level of healthcare. The analysis of the mean value does not show statistically significant difference regarding discrimination of the people living with HIV/AIDS according to the age of the interviewed health workers. Regarding discrimination according to profession, it is significant that doctors show less discrimination towards HIV-positive patients than nurses/medical technicians with university degree. The analysis of the mean value regarding additional HIV/AIDS education shows that people who had an additional HIV/AIDS education show significantly lesser level of discrimination towards the people living with HIV, i.e., they better recognize and more easily make decision to report to the supervisors any kind of discrimination towards the people living with HIV/AIDS. People living with HIV/AIDS The motive for testing on HIV for more than a half of the participants was sickness (56.3%). Of the total number of participants, 81.1% of them gave informed consent for HIV testing, and 16.2% did not give informed consent for HIV testing. The majority of participants (83.3%) were advised before and after HIV testing, while 16.7% of participants were not advised neither before nor after testing. Almost all of the participants (93.5%) said that the adviser talked to them about stigma and discrimination of people living with HIV during or after the period of HIV testing. The highest percentage of the participants (91.7%) said they have told someone about their HIV status, while only 8.3% said they have not told anyone about their HIV-positive status. Most of the people living with HIV/AIDS said they revealed their HIV status to their current partner, then to his/her sister/ brother (56.8%), to a friend (32.6%), to a health worker (27.9%). The vast majority (87.5%) of the participants who had health problems/concerns in the last 12 months sought medical assistance. Almost half of the participants (45.2%) confirmed that health worker used gloves for standard physical examination (e.g. measuring blood pressure) due to the additional precaution. 14.0% of people living with HIV confirmed that health worker refused to provide them with a healthcare service. 12.5% of PLWH confirmed that health worker revealed their HIV status to other employees. 12.2% of them confirmed they were advised to visit health institution later because health personnel working in the institution knew about their HIV-positive status. 9.8% of the participants confirmed they have been unnecessary referred to other health worker in the same or other health institution, 7.3% of the participants said they had to wait longer than usual to get the health service, 5.4% claimed they have been prematurely released from the hospital because they were HIV-positive, and 2.4% confirmed that health worker revealed their HIV-positive status to their family. 8.7% said there was no category of health workers in particular, 25.8% said medical doctors, 19.4% nurses, 12.9% stomatology doctors and 3.2% laboratory technicians. Conclusions Increasing the level of health workers’ knowledge about the ways of HIV transmission and knowledge about HIV in general, introducing and applying preventive measures for the protection of health care workers, would substantially decrease fears among health workers and would change their negative attitude towards people living with HIV.

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