HEALTH PROMOTION BEFORE THE HIV/AIDS EPIDEMIC IN PRIMARY CARE IN PUNTA ARENAS

PROMOÇÃO DA SAÚDE FRENTE À EPIDEMIA DE HIV/AIDS NA ATENÇÃO PRIMÁRIA EM PUNTA ARENAS

ABSTRACT

Objective:

to identify the attitudes and actions of health professionals in health promotion before the HIV/AIDS epidemic in Primary Health Care (PHC), Punta Arenas, Magallanes and Chilean Antartica Chilena region, Chile.

Method:

a qualitative, descriptive, and exploratory study carried out at PHC facilities in the city of Punta Arenas, Chile. Sixteen professionals who work in the five Family Health Centers participated. Data collection was carried out between March and May 2019. Data was obtained through a semi-structured interview. To organize data, ATLAS ti^® was used, which were analyzed according to thematic content analysis.

Results:

two categories have emerged. The first category, Health promotion and prevention actions before HIV/AIDS, described the actions carried out by nurses in their daily work, such as counseling on STI/AIDS prevention, sexual/reproductive health and education for professionals and the community. The second category, Nurse-midwives’ attitudes towards caring for people living with HIV/AIDS, includes caring without prejudice, active behavior and empathy due to high workload.

Conclusion:

health promotion and prevention actions carried out by PHC professionals are mainly related to counseling and education for professionals and the community. The need to integrate prevention measures with other professionals and vulnerable groups in the community stands out.

DESCRIPTORS:
HIV; Acquired Immunodeficiency Syndrome; Health personnel; Nursing; Primary prevention; Health promotion

RESUMO

Objetivo:

identificar as atitudes e ações dos profissionais de saúde na promoção da saúde frente à epidemia de HIV/Aids na Atenção Primária de Saúde, Punta Arenas, região de Magalhães e Antártica Chilena, Chile.

Método:

estudo de enfoque qualitativo, descritivo, exploratório, realizado em estabelecimentos de Atenção Primária de Saúde da cidade de Punta Arenas, Chile. Participaram 16 profissionais que atuam nos cinco Centros de Saúde da Família. A coleta de dados foi realizada entre março e maio de 2019. Os dados foram obtidos através de entrevista semiestruturada. Foi utilizado o ATLAS-ti^® para a organização dos dados, e estes foram analisados segundo a análise de conteúdo temática.

Resultados:

resultou em duas categorias. A primeira categoria, Ações de promoção da saúde e prevenção frente ao HIV/Aids descreve as ações realizadas pelas enfermeiras em seu trabalho diário, como o aconselhamento em prevenção de IST/Aids, saúde sexual/reprodutiva e a educação para profissionais e a comunidade. A segunda categoria, Atitudes das enfermeiras e parteiras frente à atenção de pessoas vivendo com HIV/Aids, abarca cuidar sem preconceitos, com escuta ativa e empatia diante da alta carga de trabalho.

Conclusão:

as ações de promoção da saúde e prevenção realizadas pelos profissionais de Atenção Primária de Saúde se relacionam principalmente com o aconselhamento e educação para profissionais e comunidade. Destaca a necessidade de transversalizar as medidas de prevenção a outros profissionais e grupos vulneráveis da comunidade.

DESCRIPTORES:
HIV; Síndrome da Imunodeficiência; Adquirida; Pessoal de saúde; Enfermagem; Prevenção primária; Promoção da saúde

RESUMEN

Objetivo:

identificar las actitudes y acciones de los profesionales de la salud en promoción de la salud frente a epidemia del VIH/SIDA en Atención Primaria de Salud, Punta Arenas, región de Magallanes y Antártica Chilena, Chile.

Método:

estudio de enfoque cualitativo, descriptivo, exploratorio, realizado en establecimientos de Atención Primaria de Salud de la ciudad de Punta Arenas, Chile. Participaron 16 professionales que desempeñan en los cinco Centros de Salud Familiar. La recolección de datos se realizó entre marzo y mayo de 2019. Los datos fueron obtenidos a través de entrevista semiestructurada. Para la organización de los datos, se utilizó ATLAS ti^®, los cuáles fueron analizados según a análisis de contenido temática.

Resultados:

se obtuvo como resultados dos categorías. La primera categoría, Acciones de promoción de la salud y prevención frente al VIH/SIDA, describiu las acciones que realizan las enfermeras en su trabajo diario, como la consejería en la prevención de ITS/SIDA, salud sexual/reproductiva y la educación para profesionales y la comunidad. La segunda categoría, Actitudes de las enfermeras y matronas frente a la atención de personas viviendo con VIH/SIDA, inclue atender sin preconceitos, com escuta activa e empatía diante da alta carga laboral.

Conclusión:

las acciones de promoción de la salud y prevención realizadas por los profesionales de Atención Primaria de Salud se relacionan principalmente con la consejería y educación para profesionales y comunidad. Destaca la necesidad de transversalizar las medidas de prevención a otros profissionales y grupos vulnerables de la comunidad.

DESCRIPTORES:
VIH; Síndrome de Inmunodeficiencia Adquirida; Personal de salud; Enfermería; Prevención primaria; Promoción de la salud

INTRODUCTION

In Chile, according to the epidemiological information available, the number of people living with HIV/AIDS has been increasing. HIV/AIDS continues to be a public health problem, with the main route of transmission of the virus being the sexual, and cases point out that sexual relations among men are the main risk practice.1

In Chile, in 2018, the notification rate is 37.5 per 100,000 inhabitants. The notification rate of HIV/AIDS cases in the Magallanes and Chilean Antartica region is 30.6 per 100,000 inhabitants, and shows a sustained increase from 2010.2

The Chilean health system is divided into public and private sectors. The public care sector covers 70% of the population. Health benefits are the responsibility of the Chilean National Health Services System (SNSS - Sistema Nacional de Servicios de Salud), which has a network of 29 Regional Health Services and a Municipal System of Primary Care. It is organized into three levels of complexity: primary, secondary, and tertiary level.3

The Magallanes region has the Magallanes Health Service (SSM - Servicio de Salud Magallanes), which reports directly to the Ministry of Health and has jurisdiction in more than ten of the eleven communities in the region. It is the body in charge of providing and managing health care and guaranteeing well-being for the population, considering the development and execution of health programs and campaigns. Punta Arenas has five Family Health Centers (CESFAM - Centros de Salud Familiar) and three Community Family Health Centers (CECOSF - Centros Comunitarios de Salud Familiar) inserted within the same population of a CESFAM. Primary Health Care (PHC) aims to provide quality and equitable care focused on people and their families, a promotional and preventive approach.

The WHO (World Health Organization) defined AIDS/HIV counseling “as a relationship of trust and dialogue with two general objectives: to prevent HIV infection and transmission and to provide psychosocial support for people directly or indirectly affected by it” (free translation). 4^:5

HIV counseling in Chile has been separated into two thematic lines:

• HIV and STD prevention counseling: this counseling assesses personal vulnerabilities and risks, provides an update on prevention measures and plans for appropriate strategies for each person. It may include exam offer if needed.

• Counseling for HIV testing and delivery of the result: it consists of guiding and supporting the informed decision to perform the HIV test and timely delivery of the result, if necessary, referral for clinical care.4

To train people assisted at PHC in their care, professionals must use care technologies, such as longitudinality; attachment; individual consultation; home visits exposed as a strategy to get to know the reality of the other and the focus between health service and user; active research; and multiprofessional service. 5

Action is the result of doing, and is defined as “any operation considered from the end of which an operation itself begins.”6^:8 Even so, actions can be free, voluntary or responsible, appropriate to man and qualified by certain conditions. The generic meaning of action implies producing, causing, acting, creating, destroying, starting, continuing, ending, etc.6

In Chile, in 2010, a study was carried out that defined attitude as a complex and multidimensional concept, as a “learned predisposition to respond in a consistently favorable or unfavorable way with respect to a given object”, and concluded that according to what they found in publications, because perception is more favorable, attitudes and knowledge have improved. 7^:347

Therefore, it is necessary to know what actions are being carried out in PHC and the attitude of health professionals, in order to implement strategies that allow increasing self-care actions in the sexuality of the community in the region.

Thus, this study aims to identify the attitudes and actions of health professionals in health promotion before the HIV/AIDS epidemic in Primary Health Care, Punta Arenas, Magallanes and Chilena Antartica region, Chile.

METHOD

This is a qualitative, descriptive, exploratory approach study, carried out in PHC facilities of the city of Punta Arenas, Magallanes region.

Primary Health Care facilities offer quality and equity care, focused on individuals and their families, focused on preventive and promotional actions. They depend administratively on the illustrious Municipal Coorporation of Punta Arenas (CORMUPA - Corporación Municipal de Punta Arenas) and technically on the health service Magallanes; they have five CESFAM that serve registered beneficiaries of the Chilean National Health Fund (FONASA - Fondo Nacional de Salud).

The research participants were nurse-midwives who work at CESFAM in Punta Arenas. Nurse-midwives who worked more than two years in the establishments were included. Initially, it was designed to interview other health professionals. Participants were selected according to availability at the time of visiting the facility. Employees who were known to be co-investigators were contacted for the first time and introduced other employees. The invitation was sent by email to the address of each establishment and they were later called by phone or in person to coordinate the interview. There were very few people who did not agree to participate, those who did not go on vacation, or there was no availability for an interview. The interviews were completed, once the sample was saturated, considering that all nurse-midwives who worked at these services and who agreed to participate in the study were interviewed.

Data collection was carried out through a semi-structured interview, approximately 25 minutes long, conducted at the workplace of each interviewee, prior coordination of date and time, between March and May 2019. Each interview it was recorded and encoded with the letter “S”, followed by a correlative number, in order to protect the identity of each interviewee.

Subsequently, these interviews were transcribed using the Word^® processor, and the ATLAS.^ti® software was used to organize the data. The data were analyzed through thematic content analysis, which was carried out according to three stages.8 The first pre-analysis stage consisted of a careful reading of all the interviews, ordering them by question. The second stage of material exploration consisted of organizing the data where the categories were created. To this end, all documents were independently coded within the software, according to which the questions were addressed. Even within the software, text segments were compared, looking for similar ideas. The encoders were the researchers themselves. The third stage was treatment of the results obtained and content interpretation. In this work, this step consisted in that, from the software, each category can be linked to the corresponding text segment to form the corpus of the work that was later interpreted. Thus, each category, as well as their relationships, were discussed in light of the literature. 8

The study was approved by the Scientific Ethics Committee of the University of Magallanes, which issued Certificate 046/CEC/2018 of validation for the study. During the elaboration and execution of this research, all ethical requirements of scientific validity were considered: favorable risk/benefit ratio, independent assessment, informed consent and respect for the enrolled subjects, among others. At all times, protection of confidentiality was guaranteed and all types of coercion were avoided. Survey results are available to participants.

RESULTS

After analyzing the data, two categories emerged: Health promotion actions and prevention before HIV/AIDS and Nurse-midwives’ attitudes towards caring for people living with HIV/AIDS.

Health promotion actions and prevention before HIV/AIDS

The first category is related to activities that health professionals carry out in their daily work in HIV/AIDS prevention, and to actions that they consider to be important to implement.

The main HIV/AIDS prevention action that nurse-midwives reported performing at their workplace is counseling, not only in STIs and HIV prevention, but also in sexual and reproductive health:

When conducting preventive medical examinations (PEM) for the community, I provide advice on how to prevent HIV and STDs and the correct use of condoms (S01).

In my work, I provide STI counseling to the general population, conducting EMPAs and workshops in schools 7 to 8 basic on sexuality and STI prevention mechanism and condom use (S08).

When I work in adolescent-friendly spaces, it is when I do most sexual and/or reproductive health counseling and also HIV prevention. I also have to take samples from VDRL and HIV tests, so I take the opportunity to counsel patients (S11).

Mainly, I do sexual and reproductive health counseling, STI and HIV prevention counseling, these activities were carried out in gynecology and/or prenatal and/or regulation control (S13).

Another preventive action that all interviewees reported taking in their daily work is related to what nurse-midwives do during care actions. Such intervention concerns using standard precautions during clinical care of users and supervision of the rest of the personnel, in order to comply with that measure:

Patients were educated on the subject, in my daily work I use standard precautions, such as wearing gloves in invasive procedures, as a preventive measure (S03).

In direct attention to users, I use universal precautions, delivering information related to the topic to users who need it, always in situations where it is possible to introduce the topic (S04).

I always use standard precautions in clinical care, such as gloves, and follow sampling protocols (S05).

I also supervise that other employees use standard preventive measures in healthcare. Sometimes I give incidental guidance on the matter to users who request It (S15).

Interviewees, when asked about the promotion and prevention actions they considered important, mentioned health education in its various fields: aimed at health personnel; to the community at different stages of the life cycle (adolescents, adults). They reinforced the use of barrier methods, such as promoting safe sex and giving users access to health control:

Lectures are given in schools in the sector, there are “friendly spaces”, aimed at teenagers, where they can solve all their doubts about sexual health (S01).

During health control, each professional educates based on the knowledge acquired (S03).

Given my social welfare work, what I do most is education and compliance with standard precautions (S15).

We make panels in the establishments so that, when users read them, offer HIV testing (S16).

When consulting interviewees on health promotion in HIV/AIDS, many participants reported that actions are scarce and limited in PHC. Actions focus on health professionals who care for women in birth control or pregnancy, so that they feel that the actions should cover other groups of people in the community or who go to CESFAM:

There is little that is done specifically on the subject in primary care, I think midwives do more promotion in their pregnancy control. I work doing healthy control for children and controlling chronic diseases; so, when I have chronic control, I take the opportunity to educate on the subject (S02).

Mainly, the women’s program is responsible, midwives deal with this process. Friendly spaces pay less attention to young people between 15 and 19 years old (S11).

It is very limited, we only do it in the women’s program, it is not transversal to the whole CESFAM health team (S13).

Most of them expressed that more efforts could be made by the entire team of health professionals in health promotion actions, transversal to all life cycles, including vulnerable groups that are generally not covered by prevention:

I think the promotion actions are regular, we still need to do more promotion (S12).

I think we still have a long way to go. We are focused on risk groups, in the distribution of leaflets, but we must start working early on the concepts of healthy sexuality; offer several alternatives of protection to the population; speak freely on the subject, workshops for parents of school children (10 to 14 years old) (S08).

All interviewees expressed having little time available to carry out community actions and health promotion, and most of activities are aimed at direct actions for patient care:

Working hours, we have many hours of patient care and few hours of work and community education (S06).

Lack of time to carry out more promotion and prevention actions (S16).

Nurse-midwives’ attitudes towards caring for people living with HIV/AIDS

The second category is nurse-midwives’ attitudes towards caring for people living with HIV/AIDS (PLHIV). Of those interviewed, four of them reported not having had the opportunity to attend PLHIV; the rest, twelve, expressed how they felt and how they acted in such situations. One of the responses that stands out is that professionals refer to PLHIV treatment without prejudice, i.e., in the same way that they care for patients with other pathologies so that they do not feel different or discriminated against:

I treated them like any patient, I tried not to make them feel that I am treating them differently from the others (S02).

Attending to the user as anyone, do not make them uncomfortable and prioritize their attention in Primary Emergency Care Services, to avoid the contagion of any microorganism that may affect their immune system (S03).

Treat them the same as all patients, without distinction. Provide adequate counseling without giving more importance to HIV itself (S05).

Active listening, if appropriate, and normal user service (S06).

Interviewees reported attitudes and feelings of respect, empathy and an attitude of equality in caring for PLHIV, and used active listening and, at times, restraint. They are always present during health care provided by education in different areas, from their pathology, from self-care, among other topics. Quality, humanized care, without discrimination, acquiring new knowledge and updating HIV/AIDS are challenges:

Acting with a good professional level, so that the care provided is of quality, humanized and in accordance with the needs of users (S02).

Acquire new knowledge on the subject, in favor of a better quality of assistance (S03).

Working hours, we have many hours of patient care and few hours of work and education in the community (S06).

When care is comprehensive, carrying out the procedures that it requires in a respectful manner, without fear of contagion, when the occasion allowed it, I tried to provide counseling on measures to prevent and control their disease (S09).

Among the attitudes of the interviewees who took care of people living with HIV/AIDS (PLHIV), they affirm the importance of meeting the needs of these people in the face of this diagnosis. Professionals must be trained and prepared for these situations, since often, when the result is delivered, emotional restraint must be made:

I also had to deliver the test results and, when positive, it was a special moment, I was nervous, but I tried to hide so that patients wouldn’t notice (S09).

As a professional available when needed, supporting the link to programs and benefits (S04).

I helped them by providing advice and education about their pathology, preventive measures, referring to the secondary level of care in a timely manner, I had to provide emotional support and also reinforced periodic control (S13).

I had to provide restraint, coordinate and refer to secondary care promptly (S16).

Another attitude mentioned by the interviewees is the motivation they provide PLHIV and other users to attend examinations, perform preventive examinations and comply with safe sexual behaviors:

My main challenge is to motivate young people, because they have little interest in having comprehensive health check-ups and using condoms (S11).

Provide counseling, motivating them to maintain periodic control and reinforcing compliance with appropriate behaviors (S12).

DISCUSSION

The results of this research show that PHC nurse-midwives in Punta Arenas carry out the actions described in the current regulations regarding HIV/AIDS. They said that the main preventive action they take is counseling, which is mandatory in the Procedures Manual for the detection and diagnosis of HIV infection.9

The second preventive action that they refer to, carried out by nurse-midwives at PHC facilities in the community of Punta Arenas, is to recognize and use standard precautions in health care. This same activity is regulated in Chile, and the components of the standard precautions that are important for prevention are hand hygiene; glove use; shield protection; prevention of punctures and cuts with sharps. Depending on the roles performed by health personnel, they should be used.10

From the point of view of health personnel’s attitudes towards people living with HIV/AIDS, it can be said that, as what was exposed by another study, they expressed empathy, active listening, respect for patients, which is positive because it decreases discrimination and negative attitudes towards them.7

Interviewees acknowledged that health promotion actions carried out were insufficient. Such actions focus on perinatal care as well as lack of time and workload to carry out more actions, exactly as was proposed in a study in the metropolitan region. This study refers to more patients to serve, more demanding and assertive users, multiple tasks to be performed simultaneously (assistance, registration, coordination, etc.) and, in the establishment, human resources not proportional to workload growth.11

The results are consistent with what was stated in a Brazilian study, in which women are submitted to exam associated with prenatal control. In Punta Arenas, women receive the greatest health benefits related to HIV prevention, as this is where these actions are focused on PHC.12

In a study,5 it has been pointed out that the starting point for the implementation of effective management of HIV/AIDS problems in PHC is establishing a bond of trust between professionals and users from the moment of diagnosis. This link between the professional and PLHIV is difficult, whether due to the impact of the disease or the personal/professional capacity to establish proper therapeutic communication. In this study, it was not possible to identify whether there is this bond of trust that they mentioned in the Brazilian study.5

Personnel training in various technical and administrative aspects of HIV/AIDS is vitally important. They establish direct contact with users, in relation to the information, to motivate the collection of samples for examination and their results, as well as the importance of health education and the relationship established with users.13

Health education focused on health promotion and HIV/AIDS prevention still shows little visibility in care provided, often revealing few interactions between nurses/health professionals and people served. Actions generally focus on specific clinical complaints or programs, emphasized in the professional training itself. In the development of actions, professionals perceive themselves as vulnerable to situations and express the need for emotional preparation to deal with the moment of revealing seropositivity, or even communicating bad news. In other words, professionals feel incapable and/or are not prepared to conduct this moment, because they identify their emotional and technical vulnerability to the situation.5 Acknowledging nursing as an important agent in the education and prevention of diseases, such as HIV/AIDS, stands out as well as the importance of teaching and research in health from this point of view.

In health, even in the face of progress in scientific knowledge, there is still a new ignorance due to the disjunction and compartmentalisation between specialized courses that prevent the conception of global and fundamental problems.14 It is relevant to emphasize that, for Morin, actions are responses consistent with complexity, which depends on intuition, on the personal characteristics of each person. Moreover, Morin states that health must be approached with a sociocultural and holistic sense, to capture man in his cosmic nature, in his relationship with nature and society. In order to work on HIV/AIDS prevention actions, it is important to take this point of view into account, since, as a health team, a philosophical understanding of health as a complex system must be achieved. It is necessary to think about the itinerary of life, the values and beliefs that man builds; to the socio-cultural practices that give it meaning, in order to reach users and understand that they must take care of themselves and prevent transmission of diseases.15

Finally, as expressed in a Brazilian study, it is important to highlight that the success of HIV/AIDS prevention strategies depends on collaboration, participation, and empowerment of health professionals and, especially, of users who require health care. 16

One of the limitations of this study is that there is no research from the perspective of persons with HIV/AIDS cared for in PHC, considering the proposed objective of this study. We chose not to include these people in this study, given the difficulty of data collection at this time.

CONCLUSION

This study allows us to recognize that health promotion and prevention actions carried out in PHC are focused on a group of professionals (nurse-midwives) who carry out perinatal control and birth control. It is necessary to integrate the issue in other care programs, such as adult, tuberculosis, adolescent programs, among others. The most frequently carried out actions are: HIV/AIDS prevention councils; incidental education of the subject; and use of standard precautions by professionals.

The team believes that more preventive actions can still be taken, such as strengthening health promotion actions and bringing this issue closer to the community but there is a lack of time, coordination or organization. They recommend that topics such as concepts of sexuality, the mode of transmission of the disease and the clinical picture be started from an early age and offer several alternatives to promote health for the population at all stages of the life cycle.

Nursing has an important action in promoting health for people with HIV/AIDS, with the aim at developing strategies for the autonomy of these people, in a dialogical perspective, that considers their life context, possibilities and existing limits, without which actions and interactions become impossible.

It is suggested that other studies consider the perspective of persons with HIV/AIDS seen at PHC as well as that of other health professionals who perform activities at PHC, which can complement the actions and attitudes of people with HIV/AIDS in this care setting in Magallanes region.

The findings of this study also reveal the need for training and professional qualification in health nursing, emphasizing the topic related to HIV/AIDS infection prevention in professional training courses. This can contribute to the development of actions in health and nursing, with better performance of professionals and greater power and capacity to carry out an expanded reading of reality. It would also contribute to assessment of their own actions, which should consider a practice based on public policies related to the subject.

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NOTES

• ORIGIN OF THE ARTICLE

  Article extracted from the thesis - Actitudes y acciones de enfermeras/os y matronas/es en promoción de la salud frente a la epidemia del VIH/SIDA de Atención Primaria en Punta Arenas, Chile, presented to the Graduate Program in Nursing, Universidade Federal de Santa Catarina, in 2019.

• APPROVAL OF ETHICS COMMITTEE IN RESEARCH

  Approved by the Ethics Committee in Research with Human Beings, Universidad de Magallanes, Certificate 046/CEC/2018.

Publication Dates

• Publication in this collection
  02 Nov 2020
• Date of issue
  2020

History

• Received
  22 Nov 2019
• Accepted
  13 July 2020