|Year : 2022 | Volume
| Issue : 1 | Page : 142-146
Awareness of the use of standard precautions during care of people living with HIV by ward attendants in Indian hospitals
Ryan Fernandez1, Tony D S. Raj1, Elsa Heylen2, Laura Nyblade3, Dhinagaran Devadass1, Krishnamachari Srinivasan4, Maria L Ekstrand5
1 Division of Medical Informatics, St. John's Research Institute, St. John's Medical College, Bengaluru, India
2 Department of Medicine, Center for AIDS Prevention Studies, University of California, San Francisco, CA, USA
3 Global Health Division, International Development Group, RTI International, Washington, DC, USA
4 Division of Mental Health and Neurosciences, St. John's Research Institute, St. John's Medical College, Bengaluru, India
5 Department of Medicine, Center for AIDS Prevention Studies, University of California, San Francisco, CA, USA; Division of Mental Health and Neurosciences, St. John's Research Institute, St. John's Medical College, Bengaluru, India
|Date of Submission||28-Oct-2021|
|Date of Acceptance||12-Feb-2022|
|Date of Web Publication||16-Mar-2022|
Dr. Ryan Fernandez
Division of Medical Informatics, St. John's Research Institute, St. John's Medical College, Koramangala, Bengaluru - 560 034, Karnataka
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Context: Standard precautions (SP) are infection prevention practices universally used during patient care to lower infection transmission. Aims: The aim of the study was to (1) assess Indian ward attendants' (WAs) knowledge, perceived efficacy, and self-efficacy regarding SP and (2) examine correlates of SP self-efficacy and intent to use unnecessary precautions during care of people living with HIV. Subjects and Methods: Data are sourced from a face-to-face baseline survey of a stigma-reduction trial among 1859 WAs from Indian hospitals. Percentages were used to describe categorical variables means and standard deviations for continuous variables. Multiple regressions examined associations between measures. Results: WAs who had heard of SP had 44% higher odds of confidently using SP than those who had not heard of them. Those aware of universal SP use were 43% more likely to feel confident in using SP but also reported greater intent to use unnecessary precautions. Conclusions: Hospitals could implement SP training for WAs, as their knowledge of universal use was lacking.
Keywords: Self-efficacy, standard precaution, ward attendants
|How to cite this article:|
Fernandez R, S. Raj TD, Heylen E, Nyblade L, Devadass D, Srinivasan K, Ekstrand ML. Awareness of the use of standard precautions during care of people living with HIV by ward attendants in Indian hospitals. Indian J Community Med 2022;47:142-6
|How to cite this URL:|
Fernandez R, S. Raj TD, Heylen E, Nyblade L, Devadass D, Srinivasan K, Ekstrand ML. Awareness of the use of standard precautions during care of people living with HIV by ward attendants in Indian hospitals. Indian J Community Med [serial online] 2022 [cited 2022 May 17];47:142-6. Available from: https://www.ijcm.org.in/text.asp?2022/47/1/142/339750
| Introduction|| |
Standard precautions (SP) are infection control practices used with all patients (universally). This includes using personal protective equipment (such as gloves, goggles, and masks) and handwashing before/after touching patients or patient material. All hospital staff including ward attendants (WAs) should have adequate knowledge and skills to implement SP, universally.
Stigma is a behavior resulting in a person who possess a particular characteristic (such as an HIV diagnosis) to be discredited. It can be driven by lack of knowledge, fear of getting infected from contact, blame, fear of social ramifications, etc.,, Among health-care workers (HCWs), it can be expressed as taking unnecessary precautions when caring for a person with the stigmatized condition.,,
Prevalence of stigma against people living with HIV (PLWH) among HCWs has been well-documented.,, In low- and middle-income countries (LMICs), poor knowledge of how to use SP correctly can cause fear among HCWs when caring for PLWH., This leads to delay in care-seeking by PLWH themselves and differential treatment or denial of care for PLWH by the HCW., Stigmatizing practices in health-care settings specific for PLWH include double gloving, burning patient linens, and charging additionally for linen and extra gloves.
In this paper, we examine the use of SP by WAs in Indian hospitals. They are housekeeping hospital staff who assist in patient care duties such as washing items, transporting patients, and changing linens. WAs usually have minimal education and minimal job training. In a study in Ghana (which included 22% WAs), SP knowledge was poor, and WAs lacked understanding of hand hygiene importance and PPE use. In a large Indian study, WAs more frequently showed negative attitudes than nurses and doctors. They more often used unnecessary precautions with PLWH. Hence, there is a need to study this group and develop training programs to implement SP.
The current paper (1) assesses Indian WAs' knowledge, perceived efficacy, and self-efficacy regarding SP and (2) examines the correlates of SP self-efficacy and intent to use unnecessary precautions (such as double gloving) when caring for PLWH.
| Subjects and Methods|| |
The data are sourced from the baseline survey of a cluster-randomized controlled trial of a stigma-reduction intervention among WAs., It was conducted in two Indian states having a high HIV prevalence. The methodology for this trial has been published previously.
The participants were consenting WAs (n = 1859), at least 18-year-old, and with at least 1-year experience, recruited from September 2014 to December 2017, from 34 hospitals in four Indian cities. After obtaining permission from the hospital, written consent was taken. Face-to-face interviews (~40 min) were conducted by the interviewer in a private space at the hospital, using a tablet computer, in the participant's preferred language (Hindi, English, or Kannada).
Demographic characteristics included age, gender, work experience, and availability of postexposure prophylaxis (PEP) drugs in their hospital “0”-No, “1”– Yes, or “2”-Haven't heard of that/Don't know what PEP is).
The participants were asked about the frequency of performing seven routine ward-specific activities, and responses were captured ranging from “0” (Never) to “3” (Often).
To assess knowledge of SP, participants were first asked if they heard of SP and their responses were captured as “0” (No) or “1” (Yes). They were then asked to identify specific SP measures from a list of nine. A dichotomous variable was constructed and scored “1” if the participants identified all the SP correctly, and “0,” otherwise. In addition, they were asked for other measures (recorded as open answers).
For assessing the importance of SP universal use, the participants were asked how important it is for HCWs to use SP with patients with five different infections, and responses ranged from “1” (Not at all important) to “4” (Very important). A dichotomous variable was created that was scored “1” if the respondent correctly answered that SP were “Very important” for all five types and was scored “0” otherwise.
Perceived response-efficacy is the perception that if SP is used correctly, they will effectively prevent infection transmission and protect HCWs., The participants were asked how certain they were that each of seven SP, if used when caring for a PLWH, would prevent HIV transmission. The responses ranged from “1” (Very uncertain) to “5” (Very certain), the number of “Very certain” responses were summed to create an index ranging from “0” to “7.”
Perceived self-efficacy is the confidence in one's ability to correctly use SP., The participants were asked about their confidence levels while performing three professional tasks. The response options ranged from “0” (I definitely cannot) to “4” (I definitely can), and a dichotomous variable was created with a score of “1” if respondents chose “I definitely can” for all three items, or “0” otherwise.
To determine the intent to use unnecessary precautions, the participants were asked what they would do in four tasks with low risk of fluid exposure (such as assisting a patient with his personal hygiene needs), and three tasks with highrisk of fluid exposure (such as cleaning up a patient's body fluids and contaminated linen), involving PLWH. The number of tasks for which they would perform the task with unnecessary precautions (e.g., double gloving) was summed up separately.
Frequencies and percentages were used for categorical variables to describe the sample. For continuous variables, means and standard deviations were used. Multiple regression analysis was used to examine the associations of the covariates SP knowledge, belief in SP response-efficacy, and frequency of performing tasks with exposure to body fluids, with three outcomes: SP self-efficacy, the intent to use unnecessary precautions in low- and in high-risk fluid-exposure tasks. Logistic regression was used for the dichotomous outcome of SP self-efficacy. The other two outcomes were count variables and analyzed through Poisson regression. We controlled for age, gender, and education, which were significantly bivariately associated with the outcomes. In addition, we included the first outcome, self-efficacy, as a predictor in both Poisson models. Model assumptions were checked to look for evidence of multicollinearity or overdispersion of the count outcomes.
All significance tests are two sided, and a P < 0.05 was considered significant. Descriptive analyses were conducted in SPSS version 25 (IBM, Armonk, New York, United States) and regressions in Stata version 15 (StataCorp LLC, College Station, Texas, United States).
The main study (ClinicalTrials.Gov Identifier: NCT02101697) was approved by the Institutional Ethics Committee, St. John's Medical College, Bangalore, with approval number 172/2011, and the Committee on Human Research, University of California, San Francisco with approval number 10-05026.
| Results|| |
Demographics are shown in [Table 1]. The participants were from private for-profit hospitals (41%), government hospitals (28%), and nonprofit hospitals (32%). They were 65% female, and almost half were under 40 years.
As shown in [Table 2], although 86% of WAs in Indian hospitals had heard of SP, only 61% knew they were to be used universally. The “mean” response-efficacy score, i.e., the mean number of SP that respondents felt “Very certain” would prevent HIV infection, was 4.9 out of seven, and 64.7% expressed self-efficacy on all items. The percentage endorsement for the individual items is listed in [Table 2]. The WAs expressed an intent to use unnecessary precautions in 3.0 out of four low-risk tasks and 2.5 out of three high-risk tasks.
The multiple regression results for the outcomes of SP self-efficacy and the intent to use unnecessary precautions are presented in [Table 3]. Was, who heard of SP, on average had 44% higher odds of self-efficacy regarding SP (adjusted odds ratio or “AOR” of 1.44; 95% confidence interval [CI] [1.08–1.93]) than those who had not heard of them. Was, who were aware that it was “Very important” to use SP universally, were on average 43% (AOR 1.43; 95% CI [1.15–1.76]) more likely to say that they “Definitely could” do all three self-efficacy items, compared to WAs who were less aware. Response-efficacy was also positively related to self-efficacy. The greater the number of SP that WAs felt were “Very certain” to prevent HIV transmission, the higher the odds of SP self-efficacy (AOR 1.23; 95% CI [1.17–1.30]).
|Table 3: Multiple regression - standard precautions self-efficacy and intent to use unnecessary precautions (n=1859)|
Click here to view
Regarding intent to discriminate, for those WAs who were aware that it was “Very important” to use SP universally, the expected number of low-risk tasks, in which they used unnecessary precautions was on average 17% (incidence rate ratio [IRR] 1.17; 95% CI [1.11–1.24]) higher than for those less aware of the importance of universal SP use. For high-risk tasks, it was on average 10% higher (IRR 1.10; 95% CI [1.03–1.17]).
| Discussion|| |
This study conducted among WAs in Indian hospitals found that, although 86% of WAs had heard of SP, only 61% knew they were to be used universally. This finding is in accordance with an earlier Indian study that found that WAs more often used SP when attending to PLWH, than other patients. Those aware of the universal use in our study reported greater confidence in their ability to use SP. However, they were also more likely to use unnecessary precautions while caring for PLWH. The WAs who were more confident that correctly used SP can prevent HIV transmission, also demonstrated greater confidence in their ability to use SP while caring for PLWH.
WAs aware that it is “Very important” to use SP universally were more likely to feel confident that they could touch, bathe, and change soiled linens of PLWH without getting infected. This is consistent with the findings of a study conducted among HCWs in another LMIC that found a positive association between SP compliance, self-efficacy, and perceived benefits. It is likely that higher perceived self-efficacy leads a person to practice SP in more situations, though the reverse is also possible (greater compliance with SP may mean that one practices them more often, resulting in an increase in self-efficacy).
WAs aware that SP should be used universally, also showed a greater intent to use unnecessary precautions. This is consistent with another study that showed the use of unnecessary precautions increased after an intervention aimed at reducing stigma and resulted in patients being treated differently.,
This study had few limitations. It was a cross-sectional analysis, so conclusions cannot be drawn regarding causality. While the study recruited participants from different hospitals, they were all in (peri-) urban areas. We assessed intent, based on self-report, rather than observing behavior. However, our findings confirm previous findings that WAs in LMICs are less likely to receive SP training compared to other health-care professions. SP training of HCWs in public health settings is often inadequate. These programs need to teach WA the importance of using SP, and the harmful effects of using unnecessary precautions that do not provide additional protection, waste resources, and appear stigmatizing when used for PLWH only. Proper and universal use of SP reduces infection risk, prevents PLWH stigmatization, and improves treatment adherence.
| Conclusions|| |
SP awareness was high, but awareness of their universal application was low in WAs. Indian hospitals need to adopt more SP job training and supervision for WAs.
Financial support and sponsorship
This research paper utilizes data from the research study titled “Reducing AIDS Stigma among Health Professionals in India.” This study was funded by the US National Institute of Mental Health, National Institutes of Health, Grant Number 5R01MH09325702 (ML Ekstrand, PI).
Conflicts of interest
There are no conflicts of interest.
| References|| |
Ferreira LA, Peixoto CA, Paiva L, Silva QC, Rezende MP, Barbosa MH. Adherence to standard precautions in a teaching hospital. Rev Bras Enferm. 2017;70:96-103. Portuguese, English. doi: 10.1590/0034-7167-2016-0138. PMID: 28226047.
Brevidelli MM, Cianciarullo TI. Psychosocial and organizational factors relating to adherence to standard precautions. Rev Saude Publica 2009;43:907-16.
Link BG, Phelan JC. Conceptualizing Stigma. Annu Rev Sociol 2001;27:363-85.
Nyblade L, Stockton MA, Giger K, Bond V, Ekstrand ML, Lean RM, et al.
Stigma in health facilities: Why it matters and how we can change it. BMC Med 2019;17:25.
Bharat S, Mahendra VS. Meeting the sexual and reproductive health needs of people living with HIV: Challenges for health care providers. Reprod Health Matters 2007;15:93-112.
Stangl AL, Earnshaw VA, Logie CH, Van Brakel W, Simbayi LC, Barré I, et al.
The health Stigma and discrimination framework: A global, crosscutting framework to inform research, intervention development, and policy on health-related stigmas. BMC Med 2019;17:31.
Feyissa GT, Lockwood C, Woldie M, Munn Z. Reducing HIV-related stigma and discrimination in healthcare settings: A systematic review of quantitative evidence. PLoS One 2019;14:e0211298.
Nyblade L, Stangl A, Weiss E, Ashburn K. Combating HIV stigma in health care settings: What works? J Int AIDS Soc 2009;12:15.
Ekstrand ML, Bharat S, Ramakrishna J, Heylen E. Blame, symbolic stigma and HIV misconceptions are associated with support for coercive measures in urban India. AIDS Behav 2012;16:700-10.
Ekstrand ML, Ramakrishna J, Bharat S, Heylen E. Prevalence and drivers of HIV stigma among health providers in urban India: Implications for interventions. J Int AIDS Soc 2013;16 3 Suppl 2:18717.
Nyblade L, Srinivasan K, Mazur A, Raj T, Patil DS, Devadass D, et al
. HIV stigma reduction for health facility staff: Development of a blended-learning intervention. Front Public Heal 2018;6:165.
Radhakrishna K, Dass D, Raj T, Rakesh D, Kishore R, Srinivasan K, et al.
Development of a novel tablet-based approach to reduce HIV stigma among healthcare staff in India. Perspect Heal Inf Manag 2017;14:1b.
Akagbo SE, Nortey P, Ackumey MM. Knowledge of standard precautions and barriers to compliance among healthcare workers in the Lower Manya Krobo District, Ghana. BMC Res Notes 2017;10:432.
Mahendra VS, Gilborn L, George B, Samson L, Mudoi R, Jadav S, et al
. Reducing AIDS-related stigma and discrimination in Indian hospitals. Horizons Final Report. New Delhi: Population Council; 2006 24-27. Available at: http://paetc.org/wp-content/uploads/2014/05/horizons.pdf
. [Last accessed on 2021 Aug 04].
Vyas KJ, Patel GR, Shukla D, Mathews WC, Vyas KJ, Patel GR, et al.
SAHARA-J: Journal of social aspects of HIV/AIDS an open access journal a comparison in HIV-associated stigma among healthcare workers in urban and rural Gujarat a comparison in HIV-associated stigma among healthcare workers in urban and rural Gujarat. J des Asp Sociaux du VIH/SIDA 2010;7:71-5.
Thrasher JF, Swayampakala K, Borland R, Nagelhout G, Yong HH, Hammond D, et al.
Influences of self-efficacy, response efficacy, and reactance on responses to cigarette health warnings: A longitudinal study of adult smokers in Australia and Canada. Health Commun 2016;31:1517-26.
Bandura A. Self-efficacy: Toward a unifying theory of behavioral change. Psychol Rev 1977;84:191-215.
Mahendra VS, Gilborn L, Bharat S, Mudoi R, Gupta I, George B, et al.
Understanding and measuring AIDS-related stigma in health care settings: A developing country perspective. SAHARA J 2007;4:616-25.
Yousafzai MT, Janjua NZ, Siddiqui AR, Rozi S. Barriers and facilitators of compliance with universal precautions at first level health facilities in northern rural Pakistan. Int J Health Sci (Qassim) 2015;9:388-99.
Ibeziako SN, Ibekwe RC. Knowledge and practice of universal precaution in a tertiary health facility. Niger J Med 2006;15:250-4.
Ferrer LM, Cianelli R, Norr KF, Cabieses B, Araya A, Irarrázabal L, et al
. Observed use of standard precautions in Chilean community clinics. Public Health Nurs 2009;26:440-8.
[Table 1], [Table 2], [Table 3]