Abstract
This article discusses the perceptions of professionals and users about counselling practices at a counselling and testing centre in Porto Alegre/RS based on interviews with 27 service users and 14 members of the staff. The following categories emerged from thematic analysis: professionals’ perceptions on counselling, users’ perceptions on counselling and changes in counselling due to the introduction of rapid test procedures. The results show that, although initially there were some imprecision and apparent contradictions in its use, rapid testing was considered an invitation to rethink practices, bringing service closer to users’ needs.
Introduction
In Brazil, the prevalence of AIDS in the population has been maintained stable at 0.6 per cent since 2004. The epidemic is concentrated in urban centres and is more prevalent in more vulnerable population subgroups (Brasil, Ministério da Saúde, 2012). Large regional differences are also observed. In 2012, the AIDS detection rate in the state of Rio Grande do Sul was 41.4 cases per 100,000 citizens and in Porto Alegre, 93.7, far above the national rate of 20.2 cases per 100,000 citizens (Brasil, 2013).
It is known that approximately 41 per cent of people initiate treatment in advanced stages of the disease (Souza et al., 2007). With the purpose of encouraging early detection of the infection and the timely start of treatment, Brazil recently determined the expansion of HIV testing through the introduction of rapid tests. This policy meets international recommendations (HAS, 2009; World Health Organization (WHO), 2010). Different studies assess the cost and efficacy of offering it to all the population (Paltiel et al., 2006; Plate, 2007) and others suggest focusing on groups considered more vulnerable (Wouters et al., 2014; Yazdanpanah et al., 2013). In Brazil, the implementation of rapid testing is justified by its efficiency and reliability, by its cost/benefit ratio, by the possibility of offering immediate support to HIV patients in the services of the Brazilian Unified Health System (Dhalia and Díaz-Bermúdez, 2007) and, especially, by the reduction in the waiting time for results (Brasil, Ministério da Saúde, 2011), which require changes in service workflow.
With the inclusion of rapid tests, psychologists assume an ethical commitment with people living with HIV/AIDS. Psychology, historically biased by an approach based on individual-centred care, when introduced in this new scenario had to redefine its relationship regarding health and society (Rasera and Issa, 2007). It has to be able to think in a human rights perspective to identify vulnerabilities and violations of rights and to promote human rights in daily work (Centro de Referência Técnica em Psicologia e Políticas Públicas (CREPOP), 2008).
In this context, counselling, which has played an important role in the AIDS epidemic in Brazil since the creation of the National Programme of STD/AIDS, re-affirms its strategic role for the quality of HIV diagnosis and care (Brasil, Ministério da Saúde, 2003). Understood as a primary prevention strategy (CREPOP, 2008), counselling involves a process of listening which is active, individual, focused on the user and based on three components: (a) educational support, guided by transmission of information and clarification of questions; (b) emotional support, offered by a sensitive listening and friendly approach; and (c) risk assessment, that favours a consideration about attitudes and values and the elaboration of strategies for reducing these risks (Brasil, Ministério da Saúde, 2003; CREPOP, 2008).
In a systematic review of 66 studies, counselling was considered a positive strategy that can have impact on the posture towards the infection and the adhesion to treatment (Soares and Brandão, 2012). It also proved to be effective in promoting strategies for coping with it (Rutledge, 2007). However, Souza et al. (2008) showed that there are some weaknesses in the way it is practised in Brazil: for instance, the fact that, despite a positive perception about the information and support received, some patients demonstrated passivity regarding the counsellor’s discourse, indicating the need for stimulating an active and autonomous attitude regarding their health. In another study (Miranda and Barroso, 2007), results showed that counselling was centred only on cognition (information and orientation), in detriment of aspects such as support, interaction, communication and reflection.
Dimenstein (2011) points to the importance of incorporating a practice that is associated with the process of an increased ‘citizenry’ and of empowerment of subjects. Correspondingly, Rasera and Issa (2007) highlight that counselling practices that try to understand subjects in their fullness, that recognise them as inserted in their social context, are able to promote well-being and community integration, favouring transformations related to a political mobilisation of the subjects.
The importance of using counselling techniques in the process of STD/HIV/AIDS testing is well known, even if its use and methods have to be reviewed in order to be adapted to a context so eclectic and rapidly changing as is the HIV/AIDS epidemics in Brazil. To this end, the objective of this study was to analyse the perceptions of users and health professionals about counselling practice, considering the changes that accompanied the use of rapid testing.
Method
The study was conducted at a Counselling and Testing Centre (CTA) of the Sanitary Dermatology Out-patients Clinic (ADS) in Porto Alegre, Rio Grande do Sul – a pioneer centre in that southern state in offering rapid testing to all users, an experience that might help other services to implement rapid testing and counselling.
It was a qualitative research of exploratory and descriptive character that investigated the perception of 27 users of the service and of 14 staff members. Table 1 shows data on the interviewees: the service users who went to CTA-ADS searching for HIV, syphilis and/or hepatitis B/C testing were identified as U1, U2 … U27, and among the interviewed staff, there were three counsellors (two of them also involved with the application of rapid test), two health managers, three physicians, two laboratory staff, three receptionists and one administrative staff. Due to confidentiality issues, socio-demographical characteristics of the health team (identified as P1, P2 … P14) will not be presented here. When presenting excerpts of interviews, those from professionals who act directly as counsellors will be identified as such.
Socio-demographic characteristics of CTA/ADS users’ sample.
MSM: men who have sex with men; STD: sexually transmitted disease.
The semi-structured interviews lasted around 30 minutes. The staff were asked to evaluate the implementation of rapid test, considering its positive and negative aspects and the unproblematic as well as the difficult aspects, taking as reference the counselling process. Service users were asked to evaluate the service, considering the characteristic of rapid testing, with specific focus on the counselling experience. The interviews were recorded, typed and digitalised, composing a single corpus, as recommended by Garay Uriarte et al. (2002). Axial codification was the following step: after the creation of the codes (categories and sub-categories), the relationship among them was established. The codes were organised along axes according to a thematic analysis of the interviews contents (Braun and Clarke, 2006). This research was authorised by the Ethics in Research Committee (CEP) of Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS).
Results
Counselling according to staff’s perception
It was found that both professionals and users, when speaking about counselling, mentioned themes related to information aspects: that it should be centred in the users’ needs and clarify their doubts. Both professionals and users highlighted the importance of emotional support and also of the bonding established between users and professionals during counselling. Another point raised by them was related to the importance of creating a space in which people feel comfortable for assessing the risk-related situations.
Informative aspects
This category describes how health professionals perceived counselling, emphasising the technical informative aspects. It was possible to identify that some professionals understood counselling exclusively as a transmission of diagnostic or information to users. In this regard, many among those who were interviewed raised concerns about how much service users were able to understand the information transmitted: Up to now there are people […] that don’t know what HIV is. Then, the counsellor has to be able to understand the [educational] level of the person that is sitting there in his office. Because, otherwise, it won’t be of any use, it will be a waste of time to speak about anything. (P2) What is the difficulty [of counselling]? It is to find out the level of understanding that the person has, isn’t it? And how prepared the person is to receive the news, but it is OK, because it is someone who is here and will have an appointment with the doctor who will say almost the same thing and … constant dripping wears the rock away, it will sink in … (P8)
One of the counsellors reported that her perception about counselling had changed: ‘We do give information, but it has to be adapted to what he brings in […] Because I worried so much about giving information that sometimes I didn’t give him any time to say the things he wanted to say. I didn’t take into account what he really wanted to know and what was important to counselling. (P14)
It was clear that professionals who had a partial understanding of the counselling technique were the ones who questioned the need and/or efficiency of the practice: ‘The training [for counselling] is very time-consuming […] to learn something that is already part of the daily routine of doctors, that is to inform a diagnosis’ (P8). The same professional says, ‘So much information given there … The girls [counsellors] pay attention, but actually it is a “fool me that I like,” you see what I mean?’
In this same direction, another professional manifested his belief that some users, especially the most vulnerable ones, are and will always be careless with their health: These people […] have different behaviours than those who don’t take risks; they have a crazier life, they are drug addicts, they say ‘oh, I did the test but I’m not going to pick it up’ […] You see, drag queens, transsexuals, they are crazy people, disturbed. (P9)
Emotional support, bonding and risk evaluation
On the other hand, many professionals pointed out to the importance of bonding and talking so that counselling can be transformed into a health educational technology. Some of those who were interviewed expressed concern about the way that some people might receive HIV diagnosis, moment in which counselling would be essential: Last week this young man came here, went to the lab and got positive. What happened was that I had to ask one of the girls to take him into a room to get the counselling that should have been given before. (P3) I think that this is the advantage that we have in the service. […]. On the pre-test, when the person starts worrying about the possibility of the disease she is already getting ready to the diagnosis. (P5)
An interviewee pointed to aspects of being open to the feelings of the user: I think that the encouragement of the CTA team is important. […] It is really hard for the person to say ‘today I woke up and I’m getting tested to HIV’. But I think the hosting, precision and nurturing that is give offer in the service is very important. They invest a lot in it, on feeling. (P4)
One counsellor reported on the importance of bonding with users: [What is important] is this, helping people to find out how they put themselves at risk and how we can help as a health professional. It is what we can do to bond, so that they will come back […] They are a person like you, sitting in the same height as you are, looking into your eyes, they tell you things they think it’s important, you also tell them. (P14)
Service user’s perception of counselling
Information aspects
Regarding the supply of information about testing and about STD/HIV/AIDS, some of the service users mentioned that they did not learn anything new: ‘[To learn] something different, like that, no. At least, I am well-informed about the issue’ (U1); ‘I’ll tell you, I’m a very well informed person, because I’m interested also because of the context in which I work, a lot happens there, right? […] So, nothing really surprises me much […] information and clarification, I have’. (U2)
Some participants mentioned which information they considered important; others highlighted the importance of having a space to clarify their doubts: ‘It is remarkable the availability they have to answer questions. I consider myself well informed, but not too much. Today I didn’t have any questions, but they were right there, ready to answer whoever wants to ask something’ (U14).
Another theme that emerged was the access to information regarding less known prevention technology, such as post-sexual exposure prophylaxis (PEP): ‘She talked to me and explained things I didn’t know. Although I work with this, I didn’t know about other things, what to look for when an accident happens, going to a health service’ (U24). Finally, an interviewee summed up the relative importance of information: The most important was what she said, that even though I knew all that information […] I kind of let it happen anyway, and that it could bring me a much bigger problem. So I kept this point and started to think about it more, to become conscious and avoid any problem. (U6)
Emotional support, bonding and risk evaluation
The presence and posture of the counsellors were considered as something that made access to testing easier: In a private laboratory you don’t have a follow-up, you get there, get tested and retrieve the result on the internet. […] here it isn’t like that. They talk to you, there is also a psychologist who will read the result of the test with you … (U7) The most positive thing is being embraced (User embracement). [I like] the human part, that when you get there they will look at you, will answer to you politely, with discretion. Everybody is there because they had sex … screwed up, actually. Professionals are ethical, they forget about personal life and offer a health service. (U14)
Another point that was emphasised by service users was the professionals’ specialised knowledge, together with confidentiality aspects: They are there to answer me. I know for sure that [what I ask} will stay there […]. We have to voice out the doubts we have, to speak up. […] The way we get attended to and the speed. Easy and simple, just like that. Without any prejudice. (U21) As I already knew this place, I knew that they deal with this topic so much, it is something that feels safe … because it’s a place that handles it, we know that people will be able to handle it. It isn’t just handling the disease; they know how to handle you. (U15)
When analysing counselling in pre- and post-tests, the interviewees were explicit about the importance that was assigned to these moments. Specially, they mentioned how they felt comfortable to talk because of the warm and respectful environment: By the facial expressions; the way they treat you … When one looks right into the eyes, the proximity […] everything started with the way they received me, respectfully and politely […] I think that this was what made me comfortable. (U23) They are prepared for that, for all kinds of people, you see? They make you comfortable. […] I didn’t expect it to be this good. (U2) During the process, people came prepared, they are very cautious, they have certain delicacy in the way they talk to you, to ask things; that way you can open up, right? (U1)
Besides this, several participants emphasised that counselling was a space to reflect about themselves and to assess the risks they face: ‘I think, firstly, it made me shake off the prejudice regarding infected people, […] it puts you on their shoes. […] and because I went through that experience it helped me to break this paradigm’ (U4); ‘(It changed my conception of) choosing an eventual partner, no one brings you written information, so there is no way for you to know’ (U6); ‘Before I take the test, and when I get the diagnosis I lift my head up and face the practices that brought me there. Why am I there? No one will infect me because I let them […]’ (U14).
Counselling appears to be vital in case of extreme vulnerability: She encouraged me. It was her sensibility, considerateness. It reassured me to take it (the test). She looked at me, I looked at her, and she said: ‘a lot of people don’t do what you do. To come in and expose themselves’. It made me open, body and soul. […] I learned to see life more carefully. To have more dignity in life. […] to open spaces, to open up a new path in life. I was already sad. I was disappointed. I already though life was no fun anymore. I even dreamed about death asking God to take me. […] the psychologist it very thoughtful, she understands you, you can express yourself with that person; to say what is going on in one’s life. You stop and see that the person really wants to help you. I looked into her eyes and realized, it’s right here. (U22)
Changes in counselling after the implementation of rapid test
In this category, we present the results concerning the perceptions regarding counselling in the new modality of testing. The main change in the process of testing is in the waiting time for the result; in traditional testing, results were available after about a week, and in the rapid test, it is available in half an hour. This was the aspect emphasised by most users; they did not mention changes in counselling related to the introduction of the rapid test: go there and take it, because it’s good, anyway, it’s fast and you get it all done in one day. All the other times I did it in a laboratory and it takes from 3 to 4 days or even 7 days, and it is hell waiting. (U11) I think it’s great. You find out quickly, don’t have to be in that expectation, the waiting. (U6) […] by the service, the agility of the thing, by the quality and the result it will bring you, […] you do something quickly and know the result right there and can treat it quicker. (U2)
In contrast, the professionals highlighted the importance of counselling in the context of rapid testing: “Because, in reality, the important part of the test isn’t the test itself because that is something mechanic. The pre-testing and post-testing are the important moments.” (P6); “With the rapid test, he can do it all in the same day […] But if the patient isn’t oriented in counselling, I believe the result isn’t good” (P2).
Furthermore, for two counsellors, the rapid test increased the responsibility of who is attending: Before, when it was the conventional test, there was the blood sample bit, it was something ‘lighter’. When one has the result in 20 minutes, one has to focus on specific things and work with the possibility of non-reagent but, mostly, with the possibility of reagent … one has to be more attentive, pay more attention. (P10) [The change] is basically to evaluate if the person is prepared to get the diagnosis right there. […] It is important, because if it’s going to be positive it will be in 30 minutes. So we need to be attentive to that. (P13)
On the downsize, one of the professionals pointed out to a possible tendency to hurrying the process as a whole: ‘Sometimes, they think everything has to be quick, including counselling, and I don’t agree. Even if the test is fast, counselling doesn’t have to be, it can cover all stages. Education, risk awareness …’ (P7). In that sense, a counsellor referred to the initial resistance of the team to the rapid test, by associating it with haste, especially because of the way it had been used in events: If the rapid test is for events, then it means that is done without counselling, then we don’t want to make it. […] That was the big change for us, to understand that the rapid test was a technology that served for us, and that we could do it carefully and respectfully with those who come here, by offering them counselling. (P13)
The new modality of testing seems to have provoked changes in the flow of the service, affecting counselling: I went in with the patient, did the counselling, collected his exam, left it processing and continued with the questions. […] It wasn’t good like that, because the patient was talking to me, but he saw his test running right there and he spent a lot of time worrying about the clock ticking by and was anxious, because the test was right there … He didn’t absorb much. Then we changed to this other way, having a room for running the tests and a room just for counselling, in two moments, pre session and post session. And we stopped doing collective counselling. (P14) The counselling, I’ll tell you, we had to do a lot of invention here, all those things I told you: tag numbers; put the nurse in the room, take the nurse out of the room; blood collection will happen here, it won’t happen here; the patient will wait with us, the patient won’t wait with us, he will wait outside … all of that we really were trying out. When we asked who we could talk to, what people are doing, there wasn’t anyone else doing, so we invented it by ourselves. (P13)
Discussion
The aim of this study was to analyse perceptions of service users and health professionals about practising counselling in a CTA, considering changes introduced with the implementation of rapid tests. Initially, a dichotomy in the speeches of the staff was identified. On one hand, there were the ones who associated counselling exclusively with the supply of information, a tendency also indicated by other studies (Miranda and Barroso, 2007; Souza et al., 2008), adding to the belief that service users did not have the potential to reflect and change. On the other hand, there were professionals who related counselling to bonding, thus offering space for emotional aspects to emerge, as well as for risk assessment. This view was also reinforced by the counsellors who were interviewed. In a study conducted in Uganda (Kiene et al., 2015), this tendency was testified by users who suggested that counselling should include, besides general information about HIV, more awareness about available treatments and possible their implications.
It is worth noting that even if counselling is a widespread practice introduced long ago by the Brazilian STD/HIV/AIDS policies, it is not fully understood by some of the workers in health services that have a CTA. Also, some of the health professionals believed that service users do not know much (and might not necessarily have conditions to process this information), as well thinking that those who knew enough and for whom information might be important, this was not the core of the reasons they sought the service. It is known that information is no longer the key for prevention of STD/HIV/AIDS, and therefore, new approaches are required by health professionals who want to contribute positively for controlling the epidemic.
In this sense, it became clear that there is a great deal of ambiguity, imprecision and apparent contradiction in the constitutive elements of counselling (as highlighted by Pupo, 2007) that may contribute for intensifying the difficulties and inconsistencies in its implementation in the context of STD/AIDS. This apparent paradox derives from the existence, on one hand, of intentionality and socially predefined objectives in counselling and, on the other hand, from the perception that it should be an individual, singular action adapted to the individual’s social, cultural and emotional context. It is important to understand the various dimensions that are implicated in the adoption of a preventive approach centred in self-care since it requires understanding social factors such as gender, sexual identity, religion and race/colour (Soares and Brandão, 2012).
As explained by Spink (2003), when a constructionist perspective is used in health – in which the knowledge brought in by the users is privileged – instilling awareness is more relevant than that of a simple explanation. In this perspective, disease becomes a psychosocial, collective and historically built phenomenon, intersected by ideological forces present within society. Therefore, to counterbalance social meanings with those that each patient brings about his condition enables building more flexible discourses in which it becomes possible to recognise the role of information giving, even when it is considered unnecessary, opening space for active listening and offering a place for emotions and support. This point of view was mentioned by some members of the CTA staff who were interviewed.
Both professionals and service users mentioned that counsellors must adapt the supply of information to the doubts and needs of the users, as also seen in the research conducted by Souza and Czeresnia (2010). In it, participants stressed that among the aspects that made HIV testing difficult was the belief that the quality of service in the Brazilian Unified Health System, SUS, was poor, involving long waiting lists, bureaucracy, slowness and lack of attention and space for questions. But, in the study here presented, service users reported positively on their counselling experiences, drawing attention to themes such as lack of judgement, lack of prejudice, confidentiality, warmth in hosting, opportunity for opening up and for exposure and, in a more extreme case, the recovery of dignity. Besides, they remarked the fact that the team was composed of STD/HIV/AIDS specialists. These aspects are part of a conception of counselling technique (Brasil, Ministério da Saúde, 2003) that offers the foundation for the achievement of the CTA’s mission, with special attention to the most vulnerable population groups (Brasil, Ministério da Saúde, 2010). Its potency comes from the fact that the service is organised to answer to the singularity of service users. ‘The other should neither be imprisoned in his previous experience nor fit into a fixed classification or definition; we must keep our ability of seeing and hearing what the other person is really going through’ (Pupo, 2013: 149).
Therefore, it is important to analyse the discourses that are present in health policies and that permeate the practices in public health services, as Perucchi et al. (2011) emphasise, with special attention to what subjects are being produced in these spaces. The authors point out to the need for questioning the truths that are legitimated by the discourses of power that are present in governmental strategies, reflecting about what are the real needs and striving to make policies get closer to what they are meant to respond. Also, they stress the role Psychology plays in the elaboration and implementation of public policies for HIV/AIDS and in reaching beyond mere assistance, promoting human rights and citizenship. In Brazil, the main theoretical landmark for STD/AIDS prevention is the notion of vulnerability. It helps to break up with the reductionism stemming from the focus on biological and individual dimensions and postulates that social, cultural and political factors are in the basis of the susceptibility to virus infection (Ferraz and Nemes, 2012). That is why the adequate use of vulnerability and human rights conceptual framework is such a challenge for counselling within health services (Pupo, 2013).
In the analysis of changes in counselling related to the introduction of rapid tests, major questions emerge, such as the impracticality of inserting the tests in the service if counselling is excluded, the need for operational adjustments in the flow of services and the interdependency of actions in this new modality of care. In general, the technology of rapid test appeared as an invitation to rethink practices, leading CTA staff to restructure their work organisation and their approach of service users. The outcomes benefited users by offering agility in the test results and bringing it closer to the existing needs.
Therefore, this study shows the importance of the practice of counselling, particularly in the context of new modalities of testing and diagnosis. A lot has to be done if we are to re-signify, transform and re-affirm the AIDS programme in the individual sphere (of users or staff) or in its social aspects. Although it concerns the experience of a reduced number of professionals and service users in one specific service, we believe that it provides useful data that, with all necessary cautions, can be used in different contexts.
Footnotes
Acknowledgements
The authors thank the State Coordination Board of STD/AIDS of Rio Grande do Sul, all the staff of the Sanitary Dermatology Out-patients Clinic (ADS) of Porto Alegre and CAPES, for granting one of the authors a post-doctorate scholarships (Proc. 10789/13-8).
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was sponsored by resources of the Project for International Technical Cooperation BRAK57, Ministry of Health, through the Department of STD, AIDS and Viral Hepatitis of the Health Surveillance Secretariat, the Brazilian Agency of Cooperation (ABC) and the United Nations Office of Drugs and Crime (UNODC).