Exploring staff attitudes to routine HIV testing in non-traditional settings: a qualitative study in four healthcare facilities.

OBJECTIVES: To explore staff attitudes towards and experiences of the implementation of routine HIV testing in four healthcare settings in areas of high diagnosed HIV prevalence. METHODS: As part of the HINTS (HIV Testing in Non-traditional Settings) Study, routine offer of an HIV test to all 16-65-year-old patients was conducted for 3 months in an emergency department, an acute admissions unit, a dermatology outpatients department and a primary care practice. The authors conducted focus groups with staff at these sites before and after the implementation of testing. Transcriptions of focus groups were subject to thematic analysis. RESULTS: Four major themes were identified: the stigma of HIV and exceptionalisation of HIV testing as a condition; the use of routine testing compared with a targeted strategy as a means of improving the acceptability of testing; the need for an additional skill set to conduct HIV testing; and the existence within these particular settings of operational barriers to the implementation of HIV testing. Specifically, the time taken to conduct testing and management of results were seen by staff as barriers. There was a clear change in staff perception before and after implementation of testing as staff became aware of the high level of patient acceptability. CONCLUSIONS: The routine offer of HIV testing in general medical services is feasible, but implementation requires training and support for staff, which may be best provided by the local sexual health service.

HIV testing in non-traditional settings--the HINTS study: a multi-centre observational study of feasibility and acceptability.

BACKGROUND: UK guidelines recommend routine HIV testing in healthcare settings if the local diagnosed HIV prevalence >2/1000 persons. This prospective study assessed the feasibility and acceptability, to patients and staff, of routinely offering HIV tests in four settings: Emergency Department, Acute Care Unit, Dermatology Outpatients and Primary Care. Modelling suggested the estimated prevalence of undiagnosed HIV infection in attendees would exceed 1/1000 persons. The prevalence identified prospectively was not a primary outcome. METHODS: Permanent staff completed questionnaires assessing attitudes towards routine HIV testing in their workplace before testing began. Subsequently, over a three-month period, patients aged 16-65 were offered an HIV test by study staff. Demographics, uptake, results, and departmental activity were collected. Subsets of patients completed questionnaires. Analyses were conducted to identify factors associated with test uptake. FINDINGS: Questionnaires were received from 144 staff. 96% supported the expansion of HIV testing, but only 54% stated that they would feel comfortable delivering testing themselves, with 72% identifying a need for training. Of 6194 patients offered a test, 4105 (66·8%) accepted (61·8-75·4% across sites). Eight individuals were diagnosed with HIV (0-10/1000 across sites) and all transferred to care. Younger people, and males, were more likely to accept an HIV test. No significant associations were found between uptake and ethnicity, or clinical site. Questionnaires were returned from 1003 patients. The offer of an HIV test was acceptable to 92%. Of respondents, individuals who had never tested for HIV before were more likely to accept a test, but no association was found between test uptake and sexual orientation. CONCLUSIONS: HIV testing in these settings is acceptable, and operationally feasible. The strategy successfully identified, and transferred to care, HIV-positive individuals. However, if HIV testing is to be included as a routine part of patients' care, additional staff training and infrastructural resources will be required.

Preventing the next 'SARS' - European healthcare workers' attitudes towards monitoring their health for the surveillance of newly emerging infections: qualitative study.

BACKGROUND: Hospitals are often the epicentres of newly circulating infections. Healthcare workers (HCWs) are at high risk of acquiring infectious diseases and may be among the first to contract emerging infections. This study aims to explore European HCWs' perceptions and attitudes towards monitoring their absence and symptom reports for surveillance of newly circulating infections. METHODS: A qualitative study with thematic analysis was conducted using focus group methodology. Forty-nine hospital-based HCWs from 12 hospitals were recruited to six focus groups; two each in England and Hungary and one each in Germany and Greece. RESULTS: HCWs perceived risk factors for occupationally acquired infectious diseases to be 1.) exposure to patients with undiagnosed infections 2.) break-down in infection control procedures 3.) immuno-naïvety and 4.) symptomatic colleagues. They were concerned that a lack of monitoring and guidelines for infectious HCWs posed a risk to staff and patients and felt employers failed to take a positive interest in their health. Staffing demands and loss of income were noted as pressures to attend work when unwell. In the UK, Hungary and Greece participants felt monitoring staff absence and the routine disclosure of symptoms could be appropriate provided the effectiveness and efficiency of such a system were demonstrable. In Germany, legislation, privacy and confidentiality were identified as barriers. All HCWs highlighted the need for knowledge and structural improvements for timelier recognition of emerging infections. These included increased suspicion and awareness among staff and standardised, homogenous absence reporting systems. CONCLUSIONS: Monitoring absence and infectious disease symptom reports among HCWs may be a feasible means of surveillance for emerging infections in some settings. A pre-requisite will be tackling the drivers for symptomatic HCWs to attend work.

Impact of being placed at risk of Creutzfeldt-Jakob disease: a qualitative study of blood donors to variant CJD cases and patients potentially surgically exposed to CJD.

BACKGROUND: The study objective was to describe the emotional and behavioural responses to Creutzfeldt-Jakob disease (CJD) risk notification. METHODS: A qualitative study using 11 participants' interviews, which were analysed thematically with Framework Analysis. PARTICIPANTS: Six participants purposively selected from people exposed to surgical instruments used previously on patients with or at risk of CJD (any type; n = 60), and 5 participants from a cohort of blood donors to patients who subsequently developed variant CJD (n = 110). RESULTS: Notification was initially a shocking event, but with no lasting emotional impact. Those notified were convinced they were at extremely low risk of CJD and coped by not thinking about the information. Disclosure outside the immediate family was limited by fears of stigma. All expressed concern about the possibility of onward transmission and agreed notification was appropriate. Individual adherence to public health precautions varied from those who did nothing, apart from not donating blood, to those who consistently followed all advice given. This variation was informed by an assumption that information was always shared among health professionals. CONCLUSIONS: Factors contributing to minimising emotional distress following notification of CJD risk were evident. We found little evidence of sustained emotional distress. However, implementation of behaviours to minimise onward transmission, particularly in health care settings, was variable - this requires further investigation.

"It took a piece of me": initial responses to a positive HIV diagnosis by Caribbean people in the UK.

How do people respond to the news that they are HIV positive? To date, there have been few published qualitative studies of HIV diagnosis experiences, and none focusing on Caribbean people. Twenty-five HIV-positive Caribbean people in London, UK, related their diagnosis experience and its immediate aftermath in semi-structured interviews. Diagnosis with HIV caused profound shock and distress to participants, as they associated the disease with immediate death and stigmatisation. The respondents struggled with "biographical disruption", the radical disjuncture between life before and after diagnosis, which led them into a state of liminality, as they found themselves "betwixt and between" established structural and social identities. Respondents were faced with multifaceted loss: of their known self, their present life, their envisioned future and the partner they had expected to play a role in each of these. A minority of accounts suggest that the way in which healthcare practitioners delivered the diagnosis intensified the participants' distress. This research suggests that healthcare practitioners should educate patients in specific aspects of HIV transmission and treatment, and engage closely with them in order to understand their needs and potential reactions to a positive diagnosis.

Coping with HIV: Caribbean people in the United Kingdom.

Although Caribbean people in the United Kingdom are increasingly being affected by HIV/AIDS, there has been no examination of how they are coping with the illness. We investigate the coping strategies of HIV-positive Caribbean people using in-depth interviews with a purposively selected group of 25 residents of South London. The main coping strategies were more cognitive than behavioral: restricted disclosure, submersion, faith, and positive reappraisal. These strategies were intertwined in complex ways, and most were rooted in contextual factors, particularly cultural ones. Themes of loss, silence, and reinvention suffused respondents' narratives. Interventions should consider the high degree of stigmatization of HIV/AIDS in the Caribbean community, reluctance to disclose, the likelihood of an initial severe reaction to diagnosis, and external stressors. HIV-positive Caribbean people who are coping well could serve as mentors and role models for poor copers and newly diagnosed patients; establishing Caribbean-specific support groups might also assist coping.

Liminal identities: Caribbean men who have sex with men in London, UK.

Accounts by 10 Caribbean men who have sex with men living in the UK reveal them to be liminal beings with unstable and unresolved identities. They are between social states: aware they are not heterosexual and not publicly recognised, or in some cases self-accepted, as homosexual. Caribbean-born respondents especially suffer from homophobia, expressing regret and disappointment at their sexuality. They may also experience cognitive dissonance - as they are aware of their conflict with the heteronormative order - they cannot resolve. Religion contributes to homophobia and cognitive dissonance particularly for Caribbean-born men, some of whom may believe a fundamental conflict exists between Christianity and homosexuality. Heterosexism and homophobia contribute to and reinforce their liminal state, by preventing transition to publicly recognised homosexual status. Respondents may engage in private and public, internal and external, overt and covert policing of their and other gay men's behaviour: through strategic pretence at heterosexuality and/or condemnation of men engaging in behaviour identifiable as stereotypically homosexual, for example. Narratives point to the need to complexify the conventional understanding of Jamaican heterosexism to explain reported variations in the degree of anti-homosexual hostility in the country.

The perceived threat of SARS and its impact on precautionary actions and adverse consequences: a qualitative study among Chinese communities in the United Kingdom and the Netherlands.

BACKGROUND: Although the SARS outbreak involved few probable cases of infection in Europe, swift international spread of infections raised the possibility of outbreaks. In particular, SARS presented a sociopsychological and economic threat to European Chinese communities because of their close links with the outbreak's origins. METHODS: A qualitative study was conducted among Chinese residents in the United Kingdom and the Netherlands to identify the origins of SARS risk perceptions and their impact on precautionary actions and adverse consequences from the perspective of vulnerable communities living in unaffected regions. Analysis was informed by protection motivation theory. RESULTS: Results revealed that information from affected Asia influenced risk perceptions and protective behavior among the Chinese in Europe when more relevant local information was absent. When high risk perceptions were combined with low efficacy regarding precautionary measures, avoidance-based precautionary action appeared to dominate responses to SARS. These actions may have contributed to the adverse impacts of SARS on the communities. CONCLUSIONS: Experiences of European Chinese communities suggest that practical and timely information, and consistent implementation of protective measures from central governments are essential to protect vulnerable populations in unaffected regions from unnecessary alarm and harm during outbreaks of emerging infections.

Sources of information and health beliefs related to SARS and avian influenza among Chinese communities in the United Kingdom and The Netherlands, compared to the general population in these countries.

BACKGROUND: Ethnic minorities in Europe such as the Chinese may need a special strategy with regard to risk communication about emerging infectious diseases. To engage them in precautionary actions, it is important to know their information sources, knowledge, and health beliefs. PURPOSE: This study's purpose is to study the use of information sources, knowledge, and health beliefs related to SARS and avian flu of Chinese people in the UK and The Netherlands, and to make comparisons with the general population in these countries. METHOD: Results of a self-administered questionnaire among 300 British/Dutch Chinese were compared to data obtained from a computer-assisted phone survey among the general population (n = 800). RESULTS: British/Dutch Chinese got most information about emerging diseases from family and friends, followed by Chinese media and British/Dutch TV. They had less confidence than general groups in their doctor, government agencies, and consumer/patient interest groups. Their knowledge of SARS was high. They had a lower perceived threat than general populations with regard to SARS and avian flu due to a lower perceived severity. They had higher self-efficacy beliefs regarding SARS and avian flu. CONCLUSION: In case of new outbreaks of SARS/avian flu in China, local authorities in the UK and The Netherlands can best reach Chinese people through informal networks and British/Dutch TV, while trying to improve confidence in information from the government. In communications, the severity of the disease rather than the susceptibility appears to need most attention.

Perceived threat, risk perception, and efficacy beliefs related to SARS and other (emerging) infectious diseases: results of an international survey.

PURPOSE: To study the levels of perceived threat, perceived severity, perceived vulnerability, response efficacy, and self-efficacy for severe acute respiratory syndrome (SARS) and eight other diseases in five European and three Asian countries. METHOD: A computer-assisted phone survey was conducted among 3,436 respondents. The questionnaire focused on perceived threat, vulnerability, severity, response efficacy, and self-efficacy related to SARS and eight other diseases. RESULTS: Perceived threat of SARS in case of an outbreak in the country was higher than that of other diseases. Perceived vulnerability of SARS was at an intermediate level and perceived severity was high compared to other diseases. Perceived threat for SARS varied between countries in Europe and Asia with a higher perceived severity of SARS in Europe and a higher perceived vulnerability in Asia. Response efficacy and self-efficacy for SARS were higher in Asia compared to Europe. In multiple linear regression analyses, country was strongly associated with perceived threat. CONCLUSIONS: The relatively high perceived threat for SARS indicates that it is seen as a public health risk and offers a basis for communication in case of an outbreak. The strong association between perceived threat and country and different regional patterns require further research.

HIV/AIDS-related stigma and discrimination: accounts of HIV-positive Caribbean people in the United Kingdom.

This paper explores the effects of HIV/AIDS-related stigma and discrimination (HASD) on HIV-positive Caribbean people in the Caribbean and the UK. In-depth, semi-structured interviews were held with a purposively selected group of 25 HIV-positive people of Caribbean origin, using primary selection criteria of sex, age, sexuality and country of birth. Interviews with respondents revealed that they are keenly aware of the stigma surrounding HIV/AIDS, which some attribute to a particularly Caribbean combination of fear of contamination, homophobia, and ignorance, reinforced by religious beliefs. In fact, religion serves a double role: underpinning stigma and assisting in coping with HIV. HASD has usually occurred where respondents have lost or do not have control over disclosure. Compared to UK-born respondents, the accounts of Caribbean-born respondents, most of whom were born in Jamaica, include more reports of severe HASD, particularly violence and employment discrimination. All respondents mobilise a variety of strategies in order to avoid HASD, which have implications for their social interactions and emotional well being. While some manage to avoid the "spoiled identity" of the stigmatised, thereby creating their own understandings of HIV infection, these may remain individual-level negotiations. HASD affects HIV-positive Caribbean people at home and in the diaspora in a variety of ways: emotionally, mentally, financially, socially and physically. Interventions specifically addressing stigma and discrimination must be formulated for the UK's Caribbean population. Tackling stigma and discrimination requires more than education; it requires "cultural work" to address deeply entrenched notions of sexuality.

How can we facilitate reliable reporting in surveys of sexual behaviour? Evidence from qualitative research.

Methodological studies examining the veracity of sexual behaviour reports frequently focus on the source of unreliable, inaccurate or inconsistent responses. This paper, instead, explores the means by which respondents might be assisted in providing an accurate account of their sexual experience. We present findings from a survey development study (second Great Britain National Survey of Sexual Attitudes and Lifestyles, development phase), which used in-depth interviews to explore respondents' experiences of completing a pilot survey of sexual behaviour. Follow up interviews were conducted across the UK with 36 of the pilot survey sample (n = 897). We explored factors that aided reliable reporting in each research format (survey and in-depth interview), as well as factors facilitating consistent reporting across formats. We show that factors such as assurances of confidentiality, survey legitimacy, rapport between interviewer and respondent and perceptions of the therapeutic benefit of disclosure can assist accurate disclosure across both survey and in-depth interview. We draw upon the strengths of qualitative methodology to make recommendations for future survey research.

Avian influenza risk perception, Europe and Asia.

During autumn 2005, we conducted 3,436 interviews in European and Asian countries. We found risk perceptions of avian influenza to be at an intermediate level and beliefs of efficacy to be slightly lower. Risk perceptions were higher in Europe than in Asia; efficacy [corrected] beliefs were lower in Europe than in Asia.

"There is such a thing as asking for trouble": taking rapid HIV testing to gay venues is fraught with challenges.

OBJECTIVES: To explore the feasibility and acceptability of offering rapid HIV testing to men who have sex with men in gay social venues. METHODS: Qualitative study with in-depth interviews and focus group discussions. Interview transcripts were analysed for recurrent themes. 24 respondents participated in the study. Six gay venue owners, four gay service users and one service provider took part in in-depth interviews. Focus groups were conducted with eight members of a rapid HIV testing clinic staff and five positive gay men. RESULTS: Respondents had strong concerns about confidentiality and privacy, and many felt that HIV testing was "too serious" an event to be undertaken in social venues. Many also voiced concerns about issues relating to post-test support and behaviour, and clinical standards. Venue owners also discussed the potential negative impact of HIV testing on social venues. CONCLUSION: There are currently substantial barriers to offering rapid HIV tests to men who have sex with men in social venues. Further work to enhance acceptability must consider ways of increasing the confidentiality and professionalism of testing services, designing appropriate pre-discussion and post-discussion protocols, evaluating different models of service delivery, and considering their cost-effectiveness in relation to existing services.

Researching sensitive issues and ethnicity: lessons from sexual health.

Researchers are generally familiar with the need to adapt their research methods in order to minimise the impact of sensitivity. However, are different considerations required for studies of ethnicity or with ethnic minority respondents? This paper provides insight into strategies used by the authors to tackle sensitivity in qualitative and quantitative research studies of sexual health and ethnicity. Drawing on examples from these studies, the paper demonstrates the relevance of Lee's model of sensitivity, and examines ways in which ethnicity may add further dimensions to our ability to understand, identify and limit sensitivity in the research process. The paper identifies techniques available to researchers for handling sensitivity in general, as well as those that may be useful for researching sensitive topics among ethnic minority populations. The paper concludes that, given the transitional and contextual nature of ethnicity and sensitivity, formulaic approaches for tackling the latter are inappropriate. Instead, strategies are best developed in collaboration with the study communities.