Midwifery(1990) 6, 33 40
© Longman Group UK Ltd 1990
Midwifery
0266 6138/90/0006 0033/810.00
HIV infection and community midwives: experience and practice Senga Bond and Tim J. Rhodes
To assess the effects of H I V infection on the work of community midwives, a postal survey of 1 in 5 in Scotland and England was carried out. The 907 respondents represent an 83% response rate. While only 1°/o of respondents had experience of patients with AIDS, 8% had been involved with known asymptomatic H I V infection and 32% had encountered those that they considered to be 'at high risk'. While the workload generated by HIV-infected patients for individual midwives at this time was small, almost all midwives themselves considered that they had a role to play in the prevention of H I V infection through health education and in counselling. While less than a quarter of those who had encountered HIV-positive patients had provided health education, more than half had done so to those worried about H I V infection and almost a quarter had counselled them. However, confidence to provide these aspects of practice was low, even among those who had received in-service education, although higher than among those who had not done so. A minority of community midwives had read policies or guidelines about aspects of practice and service provision, except for infection control where two thirds had read what they considered an adequate policy.
INTRODUCTION Even before human immunodeficiency virus (HIV) was identified, it was already clear that paediatric acquired immunodeficiency syndrome (AIDS) was a new disease that could be acquired from the mother (Oleske et al, 1983; Rubenstein et al, 1983;Joncas et al, 1983; Scott et al, 1984). Up to the end of September 1988 when the Senga Bond BA, MSc, PhD, RGN, Lecturer in Nursing Research, Health Care Research Unit, University of Newcastle upon Tyne, 21 Clarernont Place, Newcastle upon Tyne, NE2 4AA. Tim J. Rhodes BA, Research Worker, HIV Outreach Project, Birkbeck College, University of London, 16 Gower Street, London, WC1 E 6DP. (Reprint requests to SB)
Manuscript accepted 6 October 1989 D
present study was carried out there had been 9242 cases of HIV infection reported in the United Kingdom of whom 10~o were female (Communicable Disease Surveillance Centre, 1988; Communicable Diseases Scotland Unit, 1988a). While this proportion is similar to the European figure of 11 °/o female cases of AIDS (WHO, 1988), in Scotland 27% of the reported 1545 cases of HIV infection were female, of whom 78% were in the 15 to 29 year age group. At the present time the problem mainly concerns women in high risk groups; 67% of Scottish women with HIV infection were intravenous drug misusers. However, a further 13 °/o acquired the infection through heterosexual contact (Communicable Diseases Scotland Unit, 1988b). While the rate of spread of HIV infection to the heterosexual community remains uncertain, the 33
34
MIDWIFERY
findings of 1% of previously unknown H I V infection among heterosexual attenders at a sexually transmitted diseases clinic provides no grounds for complacency (Loveday et al, 1989). World Health Organization statistics report 74% of all cases of paediatric AIDS in Europe are due to mother-child transmission (WHO, 1988). While the current level of H I V infection is low, and certainly underestimated (Cox Report, 1988), the absence of an effective cure or vaccine will mean that health care professionals working in the community, including community midwives are likely to encounter patients with H I V infection. How H I V infection is influencing their role in the delivery of health care, not only to those with identified H I V infection but in the important field of health education to prevent spread of the infection, and the nature of their affective responses to this new disease lie in uncharted waters. Two parallel postal surveys were therefore undertaken in Scotland and England of all types of community nursing staff including community nurses, health visitors, school nurses, community psychiatric nurses and community midwives to consider their experience of H I V infection; to assess their perceptions of their role and preparation for practice associated with H I V ; and their knowledge and beliefs about H I V infection. This paper reports some of the findings about community midwives' experience and current practice while a subsequent paper reports their knowledge and attitudes regarding H I V infection (Bond & Rhodes, 1990). More detailed findings, and findings about the other types of community nursing staff, are reported elsewhere (Bond et al, 1988; 1989).
METHODS A two-stage sampling design was used to obtain a 1 in 5 sample of community midwives in Scotland and England. Since no national sampling frames of community midwives exist, one third of health authorities in England, stratified for regional prevalence of H I V infection, were randomly selected with a minimum of one authority in each of the 14 regions. All 15 Scottish health boards were included. A 20% random sample was
obtained from lists of names supplied by managers. Thus a random sample of 1121 community midwives was obtained. A single postal questionnaire for use with all types of community nursing staff was developed from group discussions and individual interviews. It included main sections on: demographic details, extent and nature of experience of patients associated with H I V infection; concerns about H I V infection; participation in education or training; perceptions of experience, confidence and knowledge to provide care in relation to H I V infection and other conditions; knowledge about H I V infection and AIDS, and beliefs regarding HIV-related patient groups. The survey was conducted between M a y and September 1988; up to two reminder letters and an identical questionnaire were sent to non-respondents. Because two methods of sampling were used the results from the two surveys have not been weighted to take account of regional variations in sampling fractions and response rates, and so regional and national comparisons are not made. Data were analysed using the statistical package SPSSX (SPSS Inc., 1986) and all comparisons are based on chi-squared tests. Non-response to specific questions causes a change in the denominator used to calculate responses. Figures provided in tables represent the number of valid responses.
FINDINGS O f 65 English health authorities sampled, 60 agreed to participate in the study while all 15 Scottish health boards did so. O f the 1121 midwives originally sampled, 23 were withdrawn as no longer in practice and the 907 completed questionnaires returned represent an 83% response rate. Experience o f p a t i e n t s and clients w i t h HIV-related n e e d s The amount of contact community midwives had ever had with people with proven H I V infection until the summer of 1988 was small. This experience may have been in their current or a previous job and with pregnant women, post-partum women or other patient groups. Only 1°/o of the
MIDWIFERY sample had had contact with at least one patient with AIDS while 8% had had contact with a patient positive for H I V infection but who did not have AIDS. Overall, 9% of the sample had had contact with H I V infection, and 10 of those 78 midwives were currently in double-duty posts which included community nursing. A larger proportion of respondents, 3 2 0 , had had professional contact with people whom they themselves considered to be 'at high risk' of H I V infection while one third had encountered those who had expressed worries to them about H I V infection.
Work performed with patients with H I V r e l a t e d problems O f the choices offered, the most frequently performed work with patients who had AIDS was not in the realm of providing physical care but in health education, counselling and supporting families of patients (Table 1). By comparison with patients who were H I V positive, taking blood and doing injections and dressings were more prominent. Twenty-three per cent of community midwives with experience of this kind of patient also provided health education to individual patients. While a similar pattern of work emerges with those who had expressed worries about H I V infection, the proportion ofcommunTable 1 HIM-infection-related w o r k performed by community midwives w i t h experience of HIV-related patients or clients Type of patient or client
Task Referred to General Practitioner Referred to STD clinic Dressings or injections Taken blood Group health education Health education/ advice to individual clients Provided support to the family Counselling
With AIDS (n=12)
H IV positive (n=73)
Worried about HIV (n=296)
(%)
(%)
ity midwives who provided health education and who referred patients to their general practitioner was much higher and a larger proportion were also involved in taking blood although fewer did dressings or injections. Community midwives were also involved in counselling those with H I V infection or were worried about it.
Views of appropriate work The large majority of respondents regarded the aspects of practice described in Table 2 as applicable to their work. There was a small and consistent trend for the proportions who considered them relevant in the context of H I V infection to be lower than for other conditions with the exception of sexual counselling. Those respondents who indicated that aspects of practice were applicable to their work formed the sub-group whose responses were included in analyses about feelings of confidence, knowledge and experience to undertake them. There was a dramatic decrease in the proportions of respondents who felt confident to provide health education, both to individuals and in group settings, and counselling in HIV-related situations compared with other conditions (Table 3). The aspect of practice commanding the largest proportion of confident respondents was health education to individuals and this amounted to only 21%. While those who felt confident were in the minority, relatively large proportions indicated Table 2 Percentage of c o m m u n i t y midwives w h o considered aspects of w o r k applicable to t h e m
Aspect of work 2 -1 2
15 3 25 30
43 13 13 43
1
3
13
5
23
54
7 4
8 15
12 23
35
Health education to individuals Health education to groups Sexually oriented health education to individuals Sexually oriented health education to groups Counselling Sexually oriented counselling
Applicable generally
Applicable in the context of HIV infection and AIDS
(n)
(%)
(n)
(%)
888 891
97 94
895 898
93 85
880
97
893
94
891 876
92 95
897 890
85 88
874
94
886
95
36
MIDWIFERY
Table 3 Confidence of community midwives to carry out aspects of practice they considered appropriate t o their job Sufficient confidence to provide Related to HIV infection and AIDS
Uncertain about confidence
Related to other conditions
Insufficient confidence to provide
Related to HIV infection and AIDS
Related to other conditions
Related to HIV
Aspect of work
Related to other conditions
(%)
(%)
(%)
(%)
(%)
(%)
Health education to individuals Health education to groups Counselling
84 73 67
21 12 8
10 17 22
42 50 34
6 10 11
37 38 58
infection and AIDS
Number of valid responses ranged from 765 to 860.
that they were uncertain about their confidence to provide each aspect of practice when associated with H I V infection while the majority of those who considered HIV-related counselling applicable to their practice felt lacking in confidence to carry it out. Feelings of confidence were closely related to perceived sufficiency of knowledge and experience. However, there were few respondents who felt sufficiently experienced to provide health education to individuals and even fewer who felt this way about other aspects of practice when associated with H I V infection (Table 4). Fewer were uncertain about their lack of experience and more considered that they lacked the necessary experience than lacked confidence to provide these aspects of practice when associated with H I V infection. There were no differences between those who had experience of patients with H I V infection
and those who had no such experience in their feelings of confidence or knowledge to provide any of the aspects of practice described either associated with H I V infection or with other conditions. More of those midwives who had had experience of HIV-positive patients felt sufficiently experienced to provide health education to groups (9% compared with 3%, p < 0.04) and to individuals (18% compared with 7 %, p < 0.001) and to provide counselling (7% compared with 3%, p
© Longman Group UK Ltd 1990
Midwifery
0266 6138/90/0006 0033/810.00
HIV infection and community midwives: experience and practice Senga Bond and Tim J. Rhodes
To assess the effects of H I V infection on the work of community midwives, a postal survey of 1 in 5 in Scotland and England was carried out. The 907 respondents represent an 83% response rate. While only 1°/o of respondents had experience of patients with AIDS, 8% had been involved with known asymptomatic H I V infection and 32% had encountered those that they considered to be 'at high risk'. While the workload generated by HIV-infected patients for individual midwives at this time was small, almost all midwives themselves considered that they had a role to play in the prevention of H I V infection through health education and in counselling. While less than a quarter of those who had encountered HIV-positive patients had provided health education, more than half had done so to those worried about H I V infection and almost a quarter had counselled them. However, confidence to provide these aspects of practice was low, even among those who had received in-service education, although higher than among those who had not done so. A minority of community midwives had read policies or guidelines about aspects of practice and service provision, except for infection control where two thirds had read what they considered an adequate policy.
INTRODUCTION Even before human immunodeficiency virus (HIV) was identified, it was already clear that paediatric acquired immunodeficiency syndrome (AIDS) was a new disease that could be acquired from the mother (Oleske et al, 1983; Rubenstein et al, 1983;Joncas et al, 1983; Scott et al, 1984). Up to the end of September 1988 when the Senga Bond BA, MSc, PhD, RGN, Lecturer in Nursing Research, Health Care Research Unit, University of Newcastle upon Tyne, 21 Clarernont Place, Newcastle upon Tyne, NE2 4AA. Tim J. Rhodes BA, Research Worker, HIV Outreach Project, Birkbeck College, University of London, 16 Gower Street, London, WC1 E 6DP. (Reprint requests to SB)
Manuscript accepted 6 October 1989 D
present study was carried out there had been 9242 cases of HIV infection reported in the United Kingdom of whom 10~o were female (Communicable Disease Surveillance Centre, 1988; Communicable Diseases Scotland Unit, 1988a). While this proportion is similar to the European figure of 11 °/o female cases of AIDS (WHO, 1988), in Scotland 27% of the reported 1545 cases of HIV infection were female, of whom 78% were in the 15 to 29 year age group. At the present time the problem mainly concerns women in high risk groups; 67% of Scottish women with HIV infection were intravenous drug misusers. However, a further 13 °/o acquired the infection through heterosexual contact (Communicable Diseases Scotland Unit, 1988b). While the rate of spread of HIV infection to the heterosexual community remains uncertain, the 33
34
MIDWIFERY
findings of 1% of previously unknown H I V infection among heterosexual attenders at a sexually transmitted diseases clinic provides no grounds for complacency (Loveday et al, 1989). World Health Organization statistics report 74% of all cases of paediatric AIDS in Europe are due to mother-child transmission (WHO, 1988). While the current level of H I V infection is low, and certainly underestimated (Cox Report, 1988), the absence of an effective cure or vaccine will mean that health care professionals working in the community, including community midwives are likely to encounter patients with H I V infection. How H I V infection is influencing their role in the delivery of health care, not only to those with identified H I V infection but in the important field of health education to prevent spread of the infection, and the nature of their affective responses to this new disease lie in uncharted waters. Two parallel postal surveys were therefore undertaken in Scotland and England of all types of community nursing staff including community nurses, health visitors, school nurses, community psychiatric nurses and community midwives to consider their experience of H I V infection; to assess their perceptions of their role and preparation for practice associated with H I V ; and their knowledge and beliefs about H I V infection. This paper reports some of the findings about community midwives' experience and current practice while a subsequent paper reports their knowledge and attitudes regarding H I V infection (Bond & Rhodes, 1990). More detailed findings, and findings about the other types of community nursing staff, are reported elsewhere (Bond et al, 1988; 1989).
METHODS A two-stage sampling design was used to obtain a 1 in 5 sample of community midwives in Scotland and England. Since no national sampling frames of community midwives exist, one third of health authorities in England, stratified for regional prevalence of H I V infection, were randomly selected with a minimum of one authority in each of the 14 regions. All 15 Scottish health boards were included. A 20% random sample was
obtained from lists of names supplied by managers. Thus a random sample of 1121 community midwives was obtained. A single postal questionnaire for use with all types of community nursing staff was developed from group discussions and individual interviews. It included main sections on: demographic details, extent and nature of experience of patients associated with H I V infection; concerns about H I V infection; participation in education or training; perceptions of experience, confidence and knowledge to provide care in relation to H I V infection and other conditions; knowledge about H I V infection and AIDS, and beliefs regarding HIV-related patient groups. The survey was conducted between M a y and September 1988; up to two reminder letters and an identical questionnaire were sent to non-respondents. Because two methods of sampling were used the results from the two surveys have not been weighted to take account of regional variations in sampling fractions and response rates, and so regional and national comparisons are not made. Data were analysed using the statistical package SPSSX (SPSS Inc., 1986) and all comparisons are based on chi-squared tests. Non-response to specific questions causes a change in the denominator used to calculate responses. Figures provided in tables represent the number of valid responses.
FINDINGS O f 65 English health authorities sampled, 60 agreed to participate in the study while all 15 Scottish health boards did so. O f the 1121 midwives originally sampled, 23 were withdrawn as no longer in practice and the 907 completed questionnaires returned represent an 83% response rate. Experience o f p a t i e n t s and clients w i t h HIV-related n e e d s The amount of contact community midwives had ever had with people with proven H I V infection until the summer of 1988 was small. This experience may have been in their current or a previous job and with pregnant women, post-partum women or other patient groups. Only 1°/o of the
MIDWIFERY sample had had contact with at least one patient with AIDS while 8% had had contact with a patient positive for H I V infection but who did not have AIDS. Overall, 9% of the sample had had contact with H I V infection, and 10 of those 78 midwives were currently in double-duty posts which included community nursing. A larger proportion of respondents, 3 2 0 , had had professional contact with people whom they themselves considered to be 'at high risk' of H I V infection while one third had encountered those who had expressed worries to them about H I V infection.
Work performed with patients with H I V r e l a t e d problems O f the choices offered, the most frequently performed work with patients who had AIDS was not in the realm of providing physical care but in health education, counselling and supporting families of patients (Table 1). By comparison with patients who were H I V positive, taking blood and doing injections and dressings were more prominent. Twenty-three per cent of community midwives with experience of this kind of patient also provided health education to individual patients. While a similar pattern of work emerges with those who had expressed worries about H I V infection, the proportion ofcommunTable 1 HIM-infection-related w o r k performed by community midwives w i t h experience of HIV-related patients or clients Type of patient or client
Task Referred to General Practitioner Referred to STD clinic Dressings or injections Taken blood Group health education Health education/ advice to individual clients Provided support to the family Counselling
With AIDS (n=12)
H IV positive (n=73)
Worried about HIV (n=296)
(%)
(%)
ity midwives who provided health education and who referred patients to their general practitioner was much higher and a larger proportion were also involved in taking blood although fewer did dressings or injections. Community midwives were also involved in counselling those with H I V infection or were worried about it.
Views of appropriate work The large majority of respondents regarded the aspects of practice described in Table 2 as applicable to their work. There was a small and consistent trend for the proportions who considered them relevant in the context of H I V infection to be lower than for other conditions with the exception of sexual counselling. Those respondents who indicated that aspects of practice were applicable to their work formed the sub-group whose responses were included in analyses about feelings of confidence, knowledge and experience to undertake them. There was a dramatic decrease in the proportions of respondents who felt confident to provide health education, both to individuals and in group settings, and counselling in HIV-related situations compared with other conditions (Table 3). The aspect of practice commanding the largest proportion of confident respondents was health education to individuals and this amounted to only 21%. While those who felt confident were in the minority, relatively large proportions indicated Table 2 Percentage of c o m m u n i t y midwives w h o considered aspects of w o r k applicable to t h e m
Aspect of work 2 -1 2
15 3 25 30
43 13 13 43
1
3
13
5
23
54
7 4
8 15
12 23
35
Health education to individuals Health education to groups Sexually oriented health education to individuals Sexually oriented health education to groups Counselling Sexually oriented counselling
Applicable generally
Applicable in the context of HIV infection and AIDS
(n)
(%)
(n)
(%)
888 891
97 94
895 898
93 85
880
97
893
94
891 876
92 95
897 890
85 88
874
94
886
95
36
MIDWIFERY
Table 3 Confidence of community midwives to carry out aspects of practice they considered appropriate t o their job Sufficient confidence to provide Related to HIV infection and AIDS
Uncertain about confidence
Related to other conditions
Insufficient confidence to provide
Related to HIV infection and AIDS
Related to other conditions
Related to HIV
Aspect of work
Related to other conditions
(%)
(%)
(%)
(%)
(%)
(%)
Health education to individuals Health education to groups Counselling
84 73 67
21 12 8
10 17 22
42 50 34
6 10 11
37 38 58
infection and AIDS
Number of valid responses ranged from 765 to 860.
that they were uncertain about their confidence to provide each aspect of practice when associated with H I V infection while the majority of those who considered HIV-related counselling applicable to their practice felt lacking in confidence to carry it out. Feelings of confidence were closely related to perceived sufficiency of knowledge and experience. However, there were few respondents who felt sufficiently experienced to provide health education to individuals and even fewer who felt this way about other aspects of practice when associated with H I V infection (Table 4). Fewer were uncertain about their lack of experience and more considered that they lacked the necessary experience than lacked confidence to provide these aspects of practice when associated with H I V infection. There were no differences between those who had experience of patients with H I V infection
and those who had no such experience in their feelings of confidence or knowledge to provide any of the aspects of practice described either associated with H I V infection or with other conditions. More of those midwives who had had experience of HIV-positive patients felt sufficiently experienced to provide health education to groups (9% compared with 3%, p < 0.04) and to individuals (18% compared with 7 %, p < 0.001) and to provide counselling (7% compared with 3%, p
