AIDS Care, 2015 Vol. 27, No. 2, 198–205, http://dx.doi.org/10.1080/09540121.2014.951308
Barriers to HIV counselling and testing uptake by health workers in three public hospitals in Free State Province, South Africa Rabia Khana*, Annalee Yassib, Michelle C. Engelbrechtc, Letshego Nophaled, André J. van Rensburgc and Jerry Spiegelb a
School of Population and Public Health, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada; bGlobal Health Research Program, School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada; cCentre for Health Systems Research & Development, University of the Free State, Bloemfontein, South Africa; dProvincial Occupational Health Unit, Free State province, Bloemfontein, South Africa (Received 6 March 2014; accepted 30 July 2014) Recent WHO/ILO/UNAIDS guidelines recommend priority access to HIV services for health care workers (HCWs), in order to retain and support HCWs, especially those at risk of occupationally acquired tuberculosis (TB). The purpose of this study was to identify barriers to uptake of HIV counselling and testing (HCT) services for HCWs receiving HCT within occupational health units (OHUs). Questions were included within a larger occupational health survey of a 20% quota sample of HCWs from three public hospitals in Free State Province, South Africa. Of the 978 respondents, nearly 65% believed that their co-workers would not want to know their HIV status. Barriers to accessing HCT at the OHU included ambiguity over whether antiretroviral treatment was available at the OHU (only 51.1% knew), or whether TB treatment was available (55.5% knew). Nearly 40% of respondents perceived that stigma as a barrier. When controlling for age and race, the odds of perceiving HIV stigma in the workplace among patient-care health care workers (PCHWs) were 2.4 times that for non-PCHWs [95% confidence interval (CI): 1.80–3.15]. Of the 692 survey respondents who indicated a reason for not using HIV services at the OHU, 38.9% felt that confidentiality was the reason cited. Among PCHWs, the adjusted odds of expressing concern that confidentiality may not be maintained in the OHU were 2.4 times (95% CI: 1.8–3.2) that of non-PCHWs and were higher among Black [odds ratio (OR): 2.7, CI: 1.7–4.2] and Coloured HCWs (OR: 3.0, 95% CI: 1.6–5.6) as compared to White HCWs, suggesting that stigma and confidentiality concerns are still barriers to uptake of HCT. Campaigns to improve awareness of HCT and TB services offered in the OHUs, address stigma and ensure that the workforce is aware of the confidentiality provisions that are in place are warranted.
Keywords: confidentiality; stigma; occupational health; HIV; HCT; health worker
Introduction The HIV/AIDS epidemic has created “a shortage of human resources [that] has replaced financial issues as the most serious obstacle to implementing national treatment plans” (World Health Organization, 2006, p. 20). While health care workers (HCWs) are instrumental in HIV and tuberculosis (TB) prevention, treatment and care, little evidence demonstrates that they themselves receive adequate access to these services (Yassi, O’Hara, Lockhart, & Spiegel, 2013). As HCWs are at increased risk of occupationally acquired TB (Baussano et al., 2011; Naidoo & Jinabhai, 2006; O’Donnell et al., 2010; Sissolak, Bamford, & Mehtar, 2010), and as HIV increases the risk of acquiring TB (Whitelaw, 2011) providing HCWs with access to TB and HIV services is critical to maintaining a healthy workforce. The World Health Organization, International Labor Organization, & UNAIDS (WHO/ILO/UNAIDS, 2010) guidelines advocate for priority access to health services for HCWs. One way to facilitate this access is by *Corresponding author. Email: [email protected]
© 2014 Taylor & Francis
providing HIV counselling and testing (HCT) to HCWs on-site, within hospital occupational health units (OHUs), as HCT may be a gateway to promoting HIV treatment and care. However, conflicting results exist on HCWs’ willingness to access TB and HIV services in their workplace (Buregyeya et al., 2012; Zelnick, Gibbs, Loveday, Padayatchi, & O’Donnell, 2013). Stigma and concerns about confidentiality are often cited as barriers to uptake of these services, but are largely based on qualitative studies that have not reported on barriers including duty-hour restrictions or even on the knowledge of whether HCT is available (Obermeyer, Baijal, & Pegurri, 2011; Obermeyer & Osborn, 2007). This lack of empirical evidence hinders efforts to improve utilisation of such services. The impetus for the current study began when occupational health (OH) professionals in a public hospital in the Free State Province of South Africa noted that between January and May 2011, only 121 of its 1900 HCWs accessed the HCT service. This was surprising given the estimated prevalence of HIV in the
AIDS Care adult population in South Africa is over 17% (Department of Health [DoH], 2012) and that this OHU had many of the characteristics cited in the WHO/ILO/ UNAIDS guidelines as essential for the success of such programmes (WHO/ILO/UNAIDS, 2010; Yassi et al., 2009). This article presents the results of a large survey of HCWs that aimed to improve service utilisation by identifying barriers to uptake of HIV services within the OHUs.
Method Participants and sampling In 2012, a questionnaire was distributed to a purposive sample of HCWs at three large hospitals in the Free State Province. A stratified random sampling method was not possible due to time and resource constraints. Instead, a non-random quota sampling method was used (Bryman, 2012), to ensure that the sample reflected the HCW population at the study sites with respect to the distribution of occupations (doctors, nurses, allied health professionals, administrative and support staff) as well as demographics. An a priori sampling frame was created using hospital employment data in order to determine how many HCWs would need to be surveyed to achieve a 20% sample of HCWs from the five occupational cadres. Study protocol The analysis presented here originated from a larger OH survey conducted by researchers from the DoH, the University of Free State and the University of British Columbia. Informed written and verbal consent was obtained from survey participants at the time of data collection. Two local research team members distributed questionnaires to departmental units within each hospital. HCWs within these units were then approached individually, informed of the study’s purpose and invited to participate in the survey. Those who agreed verbally were provided with the questionnaire and a written consent form to complete and sign. Participants were given a small package of snacks as appreciation. Approximately 50% more questionnaires than required by the quota were distributed to increase the likelihood of achieving the targeted sample. Instrument The survey questionnaire was developed through iterative revision among members within the research team and piloted to ensure comprehension and clarity. The questionnaire was then translated into Sesotho, back translated and revised to ensure accuracy in retaining its original meaning. The final questionnaire consisted of three sections: (1) socio-demographic information, (2)
views on workplace health and safety and (3) OHU HIV services, aiming to identify barriers to uptake of HIV services. The analysis from sections 1 and 3 is presented here. Measures Section 1 collected basic socio-demographic information (age, sex, race, occupation and hospital). Questions on each characteristic were coded into discrete categories and used as independent variables or covariates in the analysis. Section 3 aimed to identify barriers to uptake of HIV services in the study sites’ OHUs, which were used as dependent variables in the subsequent analysis. Questions were informed by existing studies and topics identified by experts (but not previously captured in the literature, e.g., fear of consequences by employer, lack of service knowledge, etc.). Questions were grouped into seven domains, described in Table 1. Data analysis Statistical analyses were conducted using Statistical Package Software for Social Science (SPSS) version 20 (IBM Corporation, Armonk, NY). Response frequencies and percentages in each category were calculated for section 1 questions and for section 3 questions using Likert or dichotomous scales. Additionally, for section 3 questions presenting “listed options”, the frequency and percentage of participants selecting each item were calculated. Bivariate and multivariate analyses Further analyses were conducted to determine the association between HCWs’ socio-demographic characteristics and their perceptions of HIV stigma and confidentiality in the workplace and the OHU. Initially, bivariate analyses were conducted using Pearson’s chisquare tests to determine crude associations between dependent and independent variables. Missing data were recorded and excluded in a case-wise manner from the bivariate analyses. Frequency and percentages of responses for all bivariate combinations of the independent and dependent variables, as well as the p-values for each chi-square test, are presented below. Finally, multivariate logistic regression (MLR) analyses were conducted to determine the relationship between the aforementioned socio-demographic variables and each dependent variable, while controlling for other covariates. The model was generated by adding independent variables found to be significantly associated with the dependent variables in the bivariate analysis, as well as all two-way interactions. Interaction terms followed by covariates were removed sequentially if they did not contribute significantly to the model based
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Table 1. Survey questions to identify reasons for lack of service uptake. Domain
General perceptions regarding HIV/AIDS
What proportion of your co-workers do you think would want to know their HIV status? What proportion of your co-workers do you think would do the following if they were told they had HIV * Would change their sexual behaviour? * Would change their work practices? * Would want to get treatment as soon as possible? If a co-worker found out that they have HIV, who do you think they are most likely to share that information with? If someone’s boss found out they had HIV, what do you think would happen to them?
Do you think there is HIV stigma in the workplace?
. . . . . .
Do you know where the occupational health service (OHS) unit or services are located? Do you know the operating times of the OHS unit? Do you know if HIV treatment is available at the OHS? Do you know if TB treatment is available at the OHS? Do you think that HCWs use the HIV/AIDS programme in the OHS unit effectively? Regarding OH practitioners: * The OH practitioners are well trained to offer HCT? * The OH practitioners encourage people to use the OHS unit for HIV/AIDS services? If you and your co-workers do not use the OHS for HIV services, tell us how likely it is that each of the factors below explains why?
Consequences of HIV in the workplace Perceptions of HIV stigma in the workplace Knowledge of the OHU
Perceptions of the OHU
Potential reasons for not using the HCT services Perceptions of confidentiality in the OHU
Do you think confidentiality is maintained in the OHS unit?
on the likelihood ratio test at a threshold of p < 0.05. The odds ratio (OR) and 95% confidence interval (95% CI) were calculated for each covariate in the final model.
Results A total of 19.4% of HCWs (n = 928) of the 5080 HCWs employed at the sampled hospitals completed the questionnaires. Socio-demographic characteristics For occupation, physicians (11.4%), nurses (18.8%) and support staff (19.7%) fell short of the targeted sample, while allied health professionals (24.5%) and administrative staff (21.1%) were above the 20% target (Table 2). The remaining socio-demographic characteristics of participants are summarised in Table 3, demonstrating that the socio-demographic profile of participants closely resembled the proportion of these characteristics within the workforce of the study sites with respect to occupation, age, race, sex and hospital. General perceptions regarding HIV and AIDS The results of questions in this domain are summarised in Table 4. Only 35.6% of HCWs believed most or all of their colleagues would want to know their HIV status. If
Table 2. Total population, targeted quota per hospital (20% sampling frame) and achieved sample by occupation (PCHW/ non-PCHW). Occupation Doctors Nurses AHPs Admin staff Support staff Total
Targeted quota (20%)
450 2052 302 975 1301 5080
90 410 61 195 260 1016
Achieved quota (%) 53 386 74 206 256 978
(11.8%) (18.8%) (24.5%) (21.1%) (19.7%) (19.4%)a
Includes three missing values where an occupation was not provided.
informed that they were HIV positive, 42% believed that most or all of their colleagues would change their sexual behaviour, 32% believed most or all would change their work practices and 72.5% believed that most or all would want to get treatment as soon as possible. Participants felt that if a co-worker discovered that they were HIV positive, they would be most likely to disclose this to their spouse/life partner (49.1%), private doctor (48.2%) and family members (39.7%). Few would share this information with their OH nurse (18.1%), supervisor (16.0%), friends (16.0%), close co-workers (14.4%), doctor in the area they work (12.6%) or union representative (3.5%). Respondents thought 14% would not share the information with anyone.
AIDS Care Table 3. Socio-demographic characteristics of survey participants and HWs at the study hospitals. Characteristic Occupation Non-PCHWa PCHWb Age 50 Race Black Coloured White Sex Male Female Hospital A B C Multiple
Sample frequency (n)
133 252 256 335
13.6 25.8 26.2 34.3
9.9 25.3 28.8 36.0
692 84 191
70.8 8.6 19.5
71.3 6.8 21.5
446 342 175 15
45.6 35.0 17.9 1.5
45.9 37.2 16.9 Unknown
Of the 461 non-PCHWs in the sample, 206 (44.6%) were administrators and 256 (55.4%) were support staff. b Of the 513 PCHWs in the sample, 386 (75.2%) were nurses, 53 (10.3%) were doctors and 74 (14.4%) were allied health professionals.
Consequences of having HIV in the workplace The majority of participants felt if an HCWs’ boss found out they had HIV, they would be supportive (60.3%) and that their boss would encourage them to get treatment (55.9%). Some (41.2%) also felt that employers would encourage HCWs to “follow all procedures to protect themselves from exposure to infectious diseases while at work”. Few (23%) felt that HCWs’ relationship with their employer would not change. Only very few worried that they would not be promoted when they should be (5.9%); they would be fired if they started missing work (3.5%); and that an HIV positive HCW would be fired the first time they broke a rule (2.7%).
Perceptions of HIV stigma in the workplace More than one-third (38.5%) indicated they believed that there was HIV stigma in the workplace. Bivariate analysis revealed a significant association between perception of HIV stigma in the workplace and a number of sociodemographic characteristics (Table 5). Based on the bivariate analysis, the variables age, race and occupation and all two-way interaction terms were entered into an MLR model. After completing the model-fitting process described in the methods, all interactions were removed. The final MLR is presented in Table 6. Tolerance values
Table 4. Results of general perceptions regarding HIV/AIDS. Item and response Proportion of co-workers perceived to want to know their HIV status Very few Some Most All Total Would change their sexual behaviour if HIV positive Very few Some Most All Total Would change their work practices if HIV positive Very few Some Most All Total Would want to get treatment as soon as possible if HIV positive Very few Some Most All Total If HIV positive, a co-worker would most likely share this with Spouse/life partner Private doctor Family members Occupational health nurse Supervisor Friends Close co-workers Doctor in charge of the area they work Union representative They would not share this information with anyone
337 252 211 137 937
34.5 25.8 21.6 14.0 95.8
248 275 253 158 934
25.4 28.1 25.9 16.2 95.5
333 286 195 118 932
34.0 29.2 19.9 12.1 95.3
93 135 223 486 937
9.5 13.8 22.8 49.7 95.8
480 471 388 177 156 156 140 123
49.1 48.2 39.7 18.1 16.0 16.0 14.4 12.6
were all well above 0.9 and no strong correlations were found among the independent variables included in the model, indicating multicollinearity was not of concern. When controlling for additional covariates, a significant relationship remained between the dependent variable (perception of HIV stigma in the workplace) and occupation (p < 0.0001), but not race (p < 0.063) or age (p < 0.090). The adjusted OR for an HCWs occupational status demonstrates that when controlling for age and race, the odds of perceiving HIV stigma in
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Table 5. Association between socio-demographic characteristics and perceived HIV stigma in the workplace.
Characteristics Occupation Non-PCHW PCHW Age 50 Race Black Coloured White Sex Male Female Hospital A B C Multiple
Perceive HIV stigma in the workplace [n (%)]
Do not perceive HIV stigma in the workplace [n (%)]
122 (27.4) 241 (48.2)
324 (72.6) 259 (51.8)
55 105 103 99
77 142 147 220