Stigma and Dissatisfaction of Health Care Personnel in HIV Response in Iran: A Qualitative Study

Introduction

AIDS is one of the biggest challenges for humanity and is considered to be one of the most significant health risk factors in the new millennium. It is recognized as the fourth leading cause of death from infectious diseases worldwide. ^1,2 For a long time, those infected with the HIV virus have not been diagnosed and treated early enough. As a result, the world faces an epidemic for which there is neither an adequate definition of treatment nor a specific cure. ^3,4 According to the latest report released by UNAIDS, in 2012 the total number of people living with HIV/AIDS was 35.3 million people around the world, with about 6 million of those people in Asia. ⁵ According to the Ministry of Health and Medical Education in Iran, at the beginning of 2013 the total number of people identified as living with HIV/AIDS in the country was 26 125, of whom 89.8% were men and 10.2% were women. Figures show an increase in the following 6 months to 27 041 people infected with HIV/AIDS, of whom 84.4% were men and 15.6% were women. The statistics indicate rapid growth in the disease, especially among women. ⁶ There have been many new cases of infection in the eastern Mediterranean region, which has the fastest growing HIV/AIDS epidemic in the world. This is also the case in Iran. ⁷ Subsequent rapid changes in the epidemiological characteristics of HIV/AIDS in Iran show an increase of 0.2%.

In order to control this disease, it is essential to solve all the problems related to treatment. ⁸ According to national guidelines, disease counseling centers in Iran are considered the core for provision of HIV/AIDS health care services for people living with HIV/AIDS. These centers offer various services to people living with HIV/AIDS, including consulting services, family planning counseling, and advice on methods to prevent transmission of the disease. Vaccines are provided for treatment of hepatitis B, tetanus, pneumococcal infections, and flu. Treatments for antiretroviral and tuberculosis prevention, in addition to laboratory services (including voluntary testing and follow-up tests) are provided. The use of condoms is also promoted. ^9,10 Other programs and services offered in the area of HIV/AIDS include the treatment of sexually transmitted diseases and improvement in the infrastructure for support of lower socioeconomic patients, families of patients, and people at risk. This also includes the counseling of staff in the treatment of patients and their families to ensure that health care personnel have a good understanding of their patients. ^11,12

According to a report published in 2006, almost 3 million health care personnel are in contact with blood-borne viruses each year. Over 90% of infections contracted by the staff occur in low-income countries, and most of them are preventable. ¹³ Although the risk of HIV infection is very low through contact with the body’s surface, there is still a risk of transmission from HIV positive patients to health care personnel, including doctors, dentists, nurses, and other health workers in hospitals. ¹⁴ Although carrying out their daily duties, doctors and medical personnel are often exposed to a variety of viral infections such as Hepatitis C Virus, Hepatitis B Virus, and HIV that can be transmitted from infected patients. ¹⁵ Given that HIV positive patients are asymptomatic, there is a long-term potential risk of infection for health care personnel. If safety procedures are not observed, health care personnel can be exposed to blood and body fluids from patients and injections. This is the greatest risk for health personnel working in this area. Consequently, it is very important that all be aware of the transmission of diseases such as HIV through a patient’s blood. ¹⁶ Because of the supposed risks of HIV infection, staff members experience a great deal of stress working with HIV positive patients. ¹⁷ HIV-infected people live under difficult and painful conditions and the heavy burden of disease. Therefore, health care personnel face many difficulties, including understanding and accepting patients, which are the most important factors influencing health care workers in their encounters with patients.

Patients need to report their illness to health services as soon as possible. Due to socioeconomic and cultural barriers, there are negative attitudes toward people with HIV/AIDS and discriminatory behavior in the provision of health and treatment services. Infected patients having HIV/AIDS have difficulty communicating with health workers in order to receive necessary care. ¹⁸ In addition, people with HIV/AIDS often experience isolation, social exclusion, and job loss, which can bring about physical and psychological problems. These problems inevitably have an adverse effect on the quality of services provided to patients with HIV/AIDS. ¹⁹ Nevertheless, according to instructions provided by the health care system, doctors in health care centers must offer good services to patients living with HIV/AIDS. ^9,10 Health care personnel, or any person or group that claims to provide services, are expected to design and participate in good programs for their patients. They are expected to learn to accept their patients on a personal level interact with them and give them sound advice based on their own experience in health care. Personnel should also have a good understanding of their patients. ^20,21 They should advise patients and teach them unique methods to live with HIV/AIDS, including how to interact with others in the community, instead of concentrating only on preventing the spread of the disease and providing a treatment plan. In addition, regional and national strategies should include more awareness and understanding of patient’s needs. It is necessary that such awareness and understanding must be rooted in real situations and experiences. Successful planning and intervention for people living with AIDS must include approaching them, carrying out in-depth interviews exploring their feelings and attitudes, understanding their outlooks on how to prevent further spread of the disease and how to have a positive, productive life while living with HIV/AIDS. Such a plan also requires regular motivational meetings and actions. ²²

With regard to the risk of the spread of infection and the increasing number of HIV positive patients in our country, it must be pointed out that there are currently no vaccines or effective treatments for this disease. It seems that the point at which the disease starts to be treated is only when a patient becomes unwell and is compelled to see doctor. However, early reporting and diagnosis is essential in order to provide more effective treatment decisions. Timely patient treatment should be the priority in the health sector, in health education, and in advancing the knowledge and methods needed to prevent transmission of these diseases.

A report published in 2011 argued for making social changes in a specific arena by studying and understanding life experiences. Using this method, a qualitative researcher can help clarify the needs of those living with HIV/AIDS. ²³ It is essential that health care workers introduce health education programs that can promote health and prevent the spread of disease in order to achieve the desired goal. Paying special attention to the problems of health care staff who work in this field and considering their difficulties can assist them in achieving this outcome. Therefore, our aim in this qualitative study is to provide better treatment for HIV positive patients by exploring the experiences of the health care staff and related obstacles.

Methods

This research was a qualitative study that examined the problems of professional and occupational health staff in providing medical services to patients living with HIV/AIDS. The participants under study were selected following several consultations at Imam Khomeini Hospital complex in Tehran. Some staff members were invited to interview. This study was based on individual interviews with health staff lasting 30 to 45 minutes each, during which health personnel expressed their professional problems. No group sessions were arranged due to lack of opportunity and insufficient spare time for clinic personnel to attend. Individual interviews were conducted with each participant and each session was taped separately. A range of health personnel who work with HIV positive patients, including a pharmacist, psychologist, blood sampler, midwife, and receptionist at the clinic provided information. At the interview sessions, each interviewee was asked to give consent for the recording of the conversation. Once permission was obtained, the interviews were conducted, recorded, and transcribed. Interviews were performed in the spring of 2015.

Results

The most significant problems highlighted in individual interviews with health care staff were as follows:

Discussion

The purpose of this study was to investigate the problems of personnel and medical staff in HIV/AIDS health care centers. This study highlighted the main problems that health care personnel face at clinics, including the lack of acceptable standards in the working environment, poor workspace safety for staff taking and testing samples from HIV positive patients, and the failure by the authorities to provide suitable equipment and facilities.

Staff complained about poor working terms and conditions. These included lack of adequate income, inadequate subsidies for expenses, lack of annual vacation time and special leave for domestic emergencies, bonuses and other job benefits.

There were also grievances regarding inadequate workspace for counseling, high numbers of patients, and overcrowding due to the limited space at the clinic. These problems were exacerbated by inadequate staffing levels, a lack of replacement staff to give support during busy periods or to replace staff on leave or off sick, and insufficiency of specialist staff in reserve. Severe stress in the workplace is also a problem, particularly in relation to some patients affected by psychoactive substances. There was also pressure on employees from dissatisfied husbands who were unhappy about their wives working at HIV/AIDS clinics. The problem reported by most health care personnel, such as blood samplers who were in contact with blood, secretions and body fluids of patients, was the risk of developing the HIV/AIDS infection.

One of the results of the present study is that the risk of occupational infection with HIV in the health care center environment is related to the exposure of percutaneous tissue to blood or bloodied fluid of patients, which occurs in more than 85% of cases. ²⁵ Another study also showed that there was a risk of medical personnel being infected with HIV through percutaneous exposure and accidental needle syringe contact. The injuries were estimated at about 6% to 30% for HIV, 0.3% for HBV, and HCV to about 1.8%. ^{26 -28} It has also been estimated that each year, medical personnel deal with 500 000 accidents involving contact with blood through the skin and mucous. These accidental exposures happen more frequently due to poor job conditions that increase the risk of infection with blood-borne pathogens. ²⁹ A study in India showed that the rate of incidents of accidental needle contact among medical staff with better work conditions and health and safety education was reduced from 38.5% of cases in 1995 to 12% of cases in 1998. ³⁰ Considering that HIV positive patients are asymptomatic for a long time, nurses are at a potential risk of infection due to regular contact with blood and body fluids of patients and those who give injections without observing safety advice are at highest risk of being infected with HIV.

Nurses are always at risk of contracting disease; however, there are no detailed statistics about transmission of HIV through job and professional activities. The Center for Disease Control and Prevention reported 57 confirmed cases and 134 suspected cases of HIV contracted through job and occupational activities. ^6,7

To prevent transmission of HIV in the workplace, standard precautions should be introduced for all patients. ^17,18 In one case report, 2 nurses who were infected with HIV through a syringe needle were diagnosed by a psychiatrist as having post-traumatic stress disorder. Their psychological symptoms included depression, anxiety, insomnia, and nightmares. They received antiviral treatment for one year. After 2 years with repeated experience of panic attacks, they returned to work. Most people exposed to such stress who follow the appropriate psychological treatment return to normal and resume work once more. However, some health care personnel affected in this way are unable to return to normal. The role of mental health professionals is very important in these cases. Statistics show that 35% of employees of such clinics have continuous stress. An additional 30% of them, due to the risk of HIV-infected needles, have left their jobs. ³¹ Staff who have more contact with secretions and body fluids of patients but less contact with needles, have less stress. However, there is more stigma for the medical staff. ^31,32 According to the results of our investigation done in coordination with other studies, health staff (especially blood sampling personnel) who have more contact with secretions, bodily fluids, and blood of patients endure stigma and more stress. Therefore, there is a requirement to create better work facilities and conditions of employment, and for authorities to provide better standard equipment with safety features to enable personnel to be able to do well in their assigned duties, with peace of mind. These developments can bring about effective improvements in relationships between patients and health care personnel and provide job satisfaction to health care staff. In organizations that are active in the service sector, including hospitals, in which most of the work depends on the goodwill and dedicated work of staff, it is important to give attention to personnel and the management of human resources because of the motivational and environmental factors that affect the people who work in and use the center. ³³ In fact, the characteristics of any job and the duties of employees are influenced by satisfaction or dissatisfaction at work. ³⁴ Each year many hospital staff members leave their jobs due to job dissatisfaction. In addition to the waste in expensive training costs is the loss of skills, expertise, and human resources. ^35,36 Furthermore, the importance of health care and therapeutic care workers is such that they ought to be managed with maximum efficiency and effectiveness. In addition to expertise, health care personnel should perform their work with love and interest. ³⁷ Therefore, it is important to notice and evaluate factors that increase the rate of job satisfaction for all employees at the center including medical staff.

Many studies have been conducted in this area. The results of various studies have shown that the most important factors that can affect the level of personnel satisfaction include proper and efficient management by the authorities, access to authorities when necessary, and proper encouragement and appreciation, including material and morale-boosting incentives for employees. Administrators must ensure that personnel feel valued in their work and provide more flexibility for staff to use their leave at times of necessity or during domestic problems. Reviews with the aim of increasing salaries and benefits are needed. ^{38 -43} Occupational problems have been pointed out such as high workloads, failure to implement terms and conditions of law affecting workplaces, demands to meet tight deadlines and targets, increased working hours, lack of or inadequate facilities, overcrowding in the workplace, poor physical arrangement of medical centers, and stress. ⁴⁴ With regard to the treatment of staff, the greatest dissatisfaction was exhibited in the rate of job stress. In a meta-analysis performed by Zangaro and Soeken, results have shown that job stress has the strongest negative relationship to job satisfaction. ⁴⁵ Stress in the hospital environment has long been mentioned as a key factor influencing job satisfaction and retention. ⁴⁶

Job satisfaction of nurses and employed staff in wards providing services to HIV positive patients has also been studied extensively. A qualitative study carried out in Vietnam has investigated job satisfaction of health care workers in the HIV/AIDS sector. The results showed that factors leading to job satisfaction among personnel in HIV treatment centers included training opportunities, social recognition, and performing meaningful tasks. Job dissatisfaction factors that were not good for the careers of such personnel included unsatisfactory compensation, lack of positive feedback, absence of support by supervisors, work-related stress from a heavy workload, fear of infection, HIV-related stigma from family, colleagues and society due to contact with patients, living with HIV, low self-esteem, and low incomes. ⁴⁷ Murphy and colleagues (2000) in Canada reported that social support and use of proper defense mechanisms can have an effect on job satisfaction and burnout among nurses caring for HIV positive patients. Bellani et al carried out a study about the relationship between demographic factors, satisfaction, and burnout among health care providers who are working with HIV positive patients and showed that 2 independent variables, fatigue and personal accomplishment, affected job satisfaction as well as a range of personal factors such as ego strength and depression. ⁴⁸ Benevides-Pereira and Das Neves Alves (2007) reported that one-fourth of personnel at health service centers received high scores on emotional exhaustion this even affected staff who worked less than 5 years in the centers. Employees were also prone to exhibit inappropriate or destructive attitudes and defense mechanisms. Li and colleagues (2007) reported that of 478 health care workers in China experienced stigma and discrimination caused by working with HIV positive patients which had a positive correlation with internalized shame (R = 0.32). In addition, health care providers experienced low institutional or organizational support (B = −0.10) and high levels of internalized shame because of working with HIV positive patients. ⁴⁹ The results of a study by Holzemer and colleagues in 2009 in 5 African countries showed that 83.7% of nurses had experienced at least one or several stigmas. ⁵⁰ There is a relationship between stigma and lack of job satisfaction and desire for nurses and people with HIV who have experienced stigma to move to other jobs. ⁴⁹ In a center caring for women, a study was performed in Kenya in relation to stigma suffered by medical personnel. The results showed that, despite all the precautions and facilities in these centers, it was still the case that women were afraid of staff and nurses due to perceived risk of HIV infection. Although local authorities want to provide more health services to care for these women, health care personnel, especially in women’s wards, have intense fear of HIV infection in the workplace through infected needles due to the stigma and discrimination associated with working with this group of patients. They were worried that, should they become infected with HIV at the workplace, people would regard them as morally corrupt people or suspect that they were in contact with HIV positive patients.

Sometimes there is even a very negative attitude to specialists. For example, personnel who work in the women’s center receive very negative comments regarding how they are willing to be in contact with patients’ blood and placental tissue, which is the most common method of transmission of the infection. These kinds of attitudes certainly have a negative effect on the work of medical staff. With regard to the private and family life of medical personnel, it has been reported that husbands who are not health workers have requested that their wives wash their hands when they come home before taking care of children or doing housework. ⁵¹ The results of the present study are in line with similar studies in terms of problems of employment at HIV/AIDS centers. All the results were synchronized and aligned perfectly with the other studies discussed herein. A stressful workplace may lead to negative results and poor treatment. These conditions can weaken the quality of patient care and result in extra costs for the entire health system. Therefore, problems that lead to job dissatisfaction and job stress in the workplace for health care workers must be identified, especially in centers dealing with HIV/AIDS. With regard to results obtained from the present study, personnel experienced stress in the performance of their work duties because of assumed risk of HIV infection in care or sampling of patients. In order for infection control to be carried out, the necessary precautions must be provided and supplies must be available to centers, including accessories and supplies for infection control such as gloves, bleach, autoclaves, and other hygiene products. The policies for HIV positive patients must be reconsidered. In addition to these policies, programs to meet health care needs must be considered. Structural and infrastructural interventions such as provision of appropriate space (private consulting rooms) and accessories (gloves, bleach, REP, etc) are needed to provide services confidentially to HIV positive patients and to protect staff against infection. ⁵¹

In addition to the items mentioned above measures, such as salary increases, supportive monitoring, stress management, ability to take advantage of leaves of absence when necessary, reduction of stigma, increased safety, and provision of more equipment in the workplace, must be implemented to improve job satisfaction of employees. Immediate measures should be taken to provide more information, instruction, and communication in the mass media to improve the public image of services for HIV and enhance safety in the workplace. If all the above proposals are implemented, they can have a positive effective on feelings of worthiness and safety for staff in their work environment.

The World Health Organization recommends that countries should improve their staff recruitment process, with the best way being the use of the available workforce and management of the migration of health care workers to other countries. This requires proper financial and nonrewards, incentives, constant improvement of knowledge and awareness, empowerment, and creation of an appropriate work environment. ⁴⁷ Evidence suggests that whenever the degree of satisfaction of personnel increases due to improvement of working conditions, the possibility of them giving up or leaving their work decreases, and whenever there is greater dissatisfaction, there is an increase in absenteeism and resignations from work. On this basis, job satisfaction encourages retention of personnel, their efficiency and quality of work. When staff members are under stress, it affects work performance. Creating comfortable facilities that encourage staff to make more of their minds and imaginations, as well as the reorganization of staff, can be considered by the authorities. ⁵²

If authorities, health practitioners and national health services have concerns over the control of HIV/AIDS, they must consider the important role of employees and providers of health care services to HIV positive patients in all areas and cases. They must put into practice policies and programs for employee retention and job satisfaction so that health care personnel are enabled to provide the best services to people living with HIV/AIDS.

Conclusion

According to the results of the present research, the most significant problems that health care staff faced were related to behavioral disease counseling at the clinic. Another crucial problem was lack of safety and standardization of work, in terms of lack of facilities, space, and appropriate equipment for self-care of personnel while working in a restrictive space. The existence of too many patients for the limited number of health care staff to cope with was also cited as a difficulty, along with inappropriateness of psychological counseling rooms in light of the need for patient confidentiality. The absence of replacement staff for employees on leave was also a concern. There were problems related to leave, inadequate income, and lack of other spiritual and material rewards. Wages compared with other sectors, especially starting salaries, were low. There was lack of support to staff by hospital authorities. It appears that authorities need to allocate more funding to create facilities and good working conditions for health care staff, so they can provide the best services and care to people living with HIV/AIDS. The main limitation of this study was that only individual interviews were conducted with health personnel due to the crowded clinic and the impossibility of giving personnel time off for group interviews even after working hours. Had group interviews taken place, they could have helped in explaining many more of the problems experienced by health care workers. In addition, interviews with doctors and specialists as well as with authorities are highly effective in studying the problems and strategies for reducing and solving the problems of health care workers. We hope that researchers will have the opportunity to carry out further studies in the continuation and completion of this study in order to resolve the problems of health care workers.