IJCRR - 5(7), April, 2013
Date of Publication: 18-Apr-2013
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ELIMINATING HEALTH DISCREPANCY AMONG HUMAN IMMUNODEFICIENCY VIRUS INDIVIDUALS: A GUIDE IN SENSITIZING THE ISSUES OF STIGMA AND DISCRIMINATION IN MANIPUR, INDIA
Author: Jennifer Kipgen, Cecilia Stalsby Lundborg
Abstract:The human immunodeficiency virus epidemic is a major public health concern and has tremendous worldwide implication. Health sector is one of the main settings where seropositive individuals experience stigma and discrimination. Due to stigma attached to this disease many were faced with difficulties in accessing health services. Eradication of health discrepancy in Manipur will require different facet that comprise of new approaches from a range of lessons in the implementation intervention of public health communities in different parts of the states and countries. The paper attempts to bring out these suggested strategies and propose that Manipur ought to improve the health services by integrating policy makers, health professionals working in Government and Private Sector along with Non Governmental Organization. There is a need to implement a course of action to remove the obstacles and henceforth provide them the health services with a user friendly environment.
Keywords: HIV, health care services, hospitals setting, stigma, Manipur.
Stigma and discrimination are two factors that need to be address to produce an effective and sustained response for HIV/AIDS prevention, care and treatment. They prevent an individuals from being tested, limiting them in seeking care and support consequently leading them in not receiving the quality care treatment(1). HIVrelated stigma and discrimination are also recognized as key barriers for not utilizing the health service facilities by the PLHA population. To mention specifically, health setting is the primary meeting place for people with HIV/AIDS. It is the arena where one gets treatment and at the same time, experience stigma and discrimination. The main factors of these discriminatory responses include lack of knowledge, its universal precautions, service provider attitudes, and perceptions that caring for PLHA is ineffective due to its incurable consequences (2). Here comes the urgency to establish a dedicated and strong collaboration which includes government, civil society and NGOs to combat the stigma and discrimination in the society. The aim of this paper is to discuss evidence based interventions applied in some countries which have helped in reducing stigma in health facilities and consider those results if it could be integrated in the context of Manipur, India. The paper begins by defining stigma and how it effects on patients, staff and the health service facility. Though many programmes have been carried out to eliminate the prejudice against PLHA in the state itself, unfortunately combating this crucial barrier still remains a challenging task.
A comprehensive literature search was carried out to identify studies that met the following selection criteria: (1) HIV/AIDS intervention studies conducted in India or abroad (2) empirical studies that report of new interventions on HIV/AIDS studies. These studies were retrieved from the electronic databases like AIDS line, Pub Med, and other online electronic journals. The keywords: HIV, AIDS, intervention programmes, implication, stigma and discrimination, health setting. A total of 22 articles were identified and compare the components with this 22 existing studies, their intervention and how they carried out those intervention strategies.
Stigma is an intricate issue that has unfathomable roots in the complex sphere of gender, race, ethnicity, class, sexuality, and culture (3). For persons living with HIV/AIDS, stigmatization and discrimination may amplify the social isolation and worsen the accessibility of health services. HIV/AIDS-related stigma is often described as a „process of devaluation? of people either living with or associated with HIV/AIDS. Discrimination follows stigma and is the unfair and unjust treatment of an individual (4). People who are stigmatized are marked as being different and are often attached to things which are embarrassing and dangerous (5). HIV stigma is shaped not only by individual views but also by larger societal and economic forces(6). Because of stigma, HIV/AIDS patient often receive inferior care or are denied services from the health service providers(7).
Impact of stigma and discrimination in the health setting: In the healthcare setting, HIV stigma and discrimination lead to barriers in access to prevention, care, and treatment services(8). The health care setting is particularly a prominent milieu for people living with HIV/AIDS (PLHA) as they often discover their status, moreover it is where they have the potential to gather information about how to care for themselves and prevent transmission to others (9). A study in Tanzania showed that most health workers showed negative attitudes towards HIV/AIDS patients in the majority of regions(10). Discrimination by health care workers towards PLHA includes: HIV testing without consent, breaches of confidentiality, denial of treatment and care, refusal of admission to hospital, refusal to operate, stopping of ongoing treatment, early discharge, judgmental and moralistic attitudes of hospital workers, physical isolation in the ward, restrictions on movement around the ward or room, restricted access to shared facilities and unnecessary precautions (11, 12). This same discrimination is observed in a study conducted by the first author among the widows living with HIV/AIDS in Manipur, India (13). The table below (Table 1) were kinds of discrimination they received while accessing the health services in different health centres.
According to the study the nurses were more discriminative (48%) as compared to the other health professionals (46%) and attendants (6%). Moreover the study also revealed the cases of burning their bedding upon discharge, refusal of the treatment on the basis of their status and using gloves during all interactions, regardless of whether physical contact occurs or not reaffirm the findings of earlier studies(14, 15). The finding showed the lack of awareness among the medical health professionals, which apparently also showed the need to educate in the field of HIV/AIDS. As the doctors and the nurses were the ones who mostly had to deal with the patients, knowledge regarding HIV/AIDS should be imparted to them in an appropriate way.
Combating stigma in health facilities:
In order to reduce stigma, focus should be direct on the Health care professionals, Government and also the PLHA. Let us begin by discussing the role of the Health Care Workers.
Health Care Professionals:
Health service providers expressed relatively high levels of fears and perceived risks for HIV transmission while offering services, care, and support for patients (16). Research conducted in Rwandan health facilities indicate that health providers have negative attitude towards patient with HIV and that they fear becoming HIV infected while dealing with the patients(17). So it could be said that some amount of discrimination is likely to remain while rendering the services as health service providers do not feel safe about themselves. Therefore, interventions need to be developed that focus particularly on reducing providers? fear of infection, in handling the PLHA patients. A part of such intervention should include discussion regarding stigma and HIV risk among providers and ways they could protect themselves against the infection in the workplace. This may help in normalization of HIV and its perceptions to its risk which eventually directs in establishing a work environment that support efforts of health service providers to protect themselves. The Rwandan study also pointed out the need for stigma reduction strategies to be institutionalized in all health service systems in order to deliver quality health services to all PLHA individuals. Health professionals play the most prominent role in health service setting. Therefore need is arise to introduce programmes that provide health workers with comprehensive training in the areas of HIV and the universal precautions that can reduce their qualms regarding the disease. Raising awareness about stigma and allowing for critical reflection on the negative consequences of stigma can be consider an essential step in the stigma reduction programme.
Government: The policy makers should try to invest in long term integrated services to promote the well being of the PLHA by integrating services that address their social and emotional needs. Government should form and implement programmes with the aim to reduce the HIV stigmatization among health service providers. There is no strong proper set of rules in the area of health setting to avoid any kind of misconception so far in the state of Manipur. This lack of recognition may lead to fatal confrontation in future. Hence Government could include a strong set of rules in the policy formulation in order to avoid any untoward incidents against the PLHA. For instance a lesson could be learned and shared from some countries where they have attained success to an extent in combating the stigma and discrimination. The first one to be discussed is from China in which they found out the competence in small group behavioural interventions learning through active participation in role-plays, group discussions, games and other interactive activities(2). To make an intervention to be effective, focus must be made on awareness of HIV policies and measures that guarantee access to universal precautions thereby increasing the level of comfort while working with PLHA. Another example is from a study conducted in Andhra Pradesh, India (18). The study reveals that over 70 percent of heath service providers shun themselves in treating people with HIV/AIDS due to its fear of infection. The finding shows the lack of understanding among the service providers in terms of the disease. To battle against stigma „Training of Trainers? was conducted though this study in which the main goal was to sensitize the field staff about HIV/AIDS related stigma and discrimination. The training also focuses on how to improve technical skills among the health service providers. During the session a committee was formed based on anti-stigma or anti-violence at village and block levels. They include all categories of health service providers and all health institutions for creating a linkage between government and private health service providers. In this way they were able to create one common platform for addressing stigma and violence issues hence sensitizing the government health services about stigma and violence by making them more responsive. It is to mention that the workshop had used a participatory, “learning through doing” approach that resulted in health service providers intermingle enthusiastically across their specialized field. Similarly an intervention research study was conducted in four hospitals of Vietnam to address stigma and discrimination issues and also to improve the quality of care in the hospital setting (19). During the study, a training session was conducted which was co –facilitated by people living with HIV/AIDS. The outcome of the study reveals that it is necessary to involve all categories of hospital employees in training and in policy development in order to establish a stigma liberated environment. Apart from the existing essential programme that the state government is initiating to curtail the stigma and discrimination catastrophe, it would be worthwhile if it establishes a similar kind of programme and put into practice to bring down the stigmatizing behaviour among the health professionals. Government with support from NGOs and Lawyers, should engage with professional health care associations and civil society towards strengthening the efforts in giving training to health care professionals on issues of nondiscrimination, informed consent, confidentiality and patient rights. In this way it will ensure that staffs within the health care settings will provide care to all populations in an approach that is fair and protective of their human rights.
People Living with HIV/AIDS
As PLHA are the one who face the stigmatization, they are the most appropriate who can provide necessary viewpoint when it comes to combating the issues of stigma and discrimination. It is very crucial to strengthen the capability of the right of PLHA by providing the information regarding their rights. They should be empower and encourage by supporting the PLHA organizations and networks. This will enabled them to demand the recognition of their existence, needs, and rights. The PLHA organization has help to form support groups and SHGs (self help groups) and enabled those who are marginalized to challenge discrimination. In fact such kinds of organizations appear as a liberator especially for widows living with HIV/AIDS, who are left with no social support in the state of Manipur. Another lesson which could be learned is from the Brazilian experience. The approach was initiated by a group who identified themselves to be the country?s first self-identified group for people living with HIV. This Group pressurise the politicians to improve treatment and care for people living with HIV/AIDS (20). The result of this group was astonishing as it directs the Government to form a new Constitution in Brazil that focus particularly on human rights. This Constitution became very momentous as it included articles that gave the legal protection against discrimination and safeguarded their right to free healthcare. Apart from the government?s optimistic reaction towards this subject, involvement and participation of civil society groups and PLHA has been the most stupendous feature of Brazil?s response. Even the human rights movement that surface in Brazil during the 80s was vigorous and energetic in fight against HIV/AIDS related discrimination encouraging the government to guard the rights of people living with HIV. The government has since shown assurance and pledge to protect the rights of these marginalized groups. Henceforth Brazil became a rare example of a country that administers to curtail the discrimination crisis. There is an immense need of making PLHA aware concerning their individual rights, which will allow them to exercise and making them free from all social discrimination.
In many countries governments are now developing strategies that can integrate both care and treatment for those infected with HIV. There is an explicable and urgent need for direction in Manipur, a hard hit HIV state which is said to be poorly developed in terms of health systems. Experts and professional?s opinion, political judgement, and views from stakeholders and contingencies are all relevant inputs in the decision making and the formulation of policy. Since evidence from the research on contextual factors is often limited, or sometimes completely lacking. The decision makers most often regard as idiomatic evidence when compiling information on context- dependent factors(21). Therefore while framing any policies, policy makers should also consult successful case studies, for they represent valuable insights in how to execute these interventions. Once the policy is framed, it is suggested to identify how these could be implement to the best. Here it is to note that before any intervention is used, the exact situation of the problems should be diagnosed. Besides there is a need to monitored and evaluate the programme once it is implemented, as often, there is an assumption that the programme is continuing effectively which is not so on the other hand. Moreover a need to identify the tools for evaluating the programs in an effective manner is required. Programmes must have the mechanisms that will enable careful self review, approaches, impact with feedback from the PLHA to see the appropriateness and effectiveness of the intervention offered. If it is carried out in this matter there is a possibility that any unintentionally harm maybe avoided. It is necessary to improve understanding of the health professional in the health service setting by rising awareness at all levels through advocacy and social mobilization. Government must find ways to bring together ministries of NGOs, social welfare, church leaders, social scientist and PLHA and coordinate in an effective way to eradicate the stigma and discrimination issue. It should be a process led by national, regional or local government. The health service sector is both a condition for a successful reform and an obstacle for reform processes given it resistance to change.
We thank Erasmus Mundus (an exchange project funded by the European Commission) for giving the opportunity to the first author to carry out her research which will benefit the widows living with HIV/AIDS in Manipur. We acknowledge the great help received from the scholars whose articles we cited and included in references of this manuscript. The authors are grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed. Authors are also grateful to IJCRR editorial board members and IJCRR team of reviewers who have helped to bring quality to this manuscript.
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