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Enfermería Global
versión On-line ISSN 1695-6141
Enferm. glob. vol.21 no.68 Murcia oct. 2022 Epub 28-Nov-2022
https://dx.doi.org/10.6018/eglobal.510931
Originals
Representational content of professionals of the health care network about HIV in counseling
1Nurse. Doctor in Nursing. Adjunct Professor at the University of Pernambuco, Petrolina Campus, Petrolina, PE, Brazil. amanda.gois@upe.br
2Nurse. Doctor in Nursing. Associate Professor at the University of Pernambuco, Recife, PE, Brazil
3Doctor. Doctor in Sociology. Associate Professor at the Federal University of Pernambuco, Recife, PE, Brazil
4Nurse. Doctor in Public Health. Full Professor at the State University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
Objective:
To analyze the representational contents of health care professionals about human immunodeficiency virus in counseling.
Method:
Study of social representations with a procedural approach of the descriptive-exploratory type conducted with 30 professional counselors from 17 points of the health care network in the period from June 2017 to February 2018 in accordance with the COREQ. Data were collected from the techniques of interviews and observation. The corpus was elaborated and submitted to thematic-categorical content analysis with support from the ATLAS.ti 8.0 software.
Results:
The following categories emerged: social prejudices that compromise the confidentiality and privacy in the reception; vulnerabilities that consolidate pre-test counseling; and serological condition and treatment that impose urgency to testing. The representational contents about the human immunodeficiency virus, such as social prejudices, vulnerabilities, serological condition, and treatment, are related to the difficulties in ensuring confidentiality and privacy in the welcoming practices, the emphasis of pre-test counseling, and the urgency of testing according to the care point.
Conclusion
The analysis of the representational contents revealed that the communication of the diagnosis of HIV should be guided by the perspectives of health promotion and network health care. As for the implications for Nursing, it is considered that it provides directions and actions that enhance the appropriate professional performance, consequently improving the assistance to people. In order that the understanding of intersubjective aspects can subsidize favorable conditions in counseling at all points of the health care network.
Keywords: Social Perception; Professional Practice; Health Care; Counseling; HIV; Nursing
INTRODUCTION
The Brazilian and global history of the human immunodeficiency virus (HIV) epidemic is marked by profound epidemiological, social, and political transformations1,2. These transformations are perceived from the ways of presenting concepts and images to attitudes about the virus, which made it a sensitive social phenomenon and, therefore, susceptible to social representations3,4.
The most recent concerns about the epidemic are the increasing number of new cases in specific populations, the compromised quality of life and social relationships due to the normalization of HIV as a chronic health condition, and the economic impact on health systems after the expansion of testing and treatment in the health care network2)(4)(5)(6)(7)(8)(9.
About the Health Care Network (HCN), it is defined as polyarchic organizational arrangements that contemplate various technological densities, called health care levels of actions and health care and support services, centralized and coordinated by the Primary Health Care (PHC), which must respond quickly to acute situations and manage chronic health conditions10,12.
In HCN, health communication related to HIV diagnosis is carried out through the provision of testing, counseling, and treatment addressing issues and elements of social interaction with an impact on people's health status and health work relationships involving motivation, opportunity, and capacity. And it happens with different theoretical, technical, and methodological contributions, as shown in studies conducted in sub-Saharan African countries, the region most affected by HIV in recent years1, and other Asian and European countries on the subject6)(7)(8)(9.
This study aimed to analyze the representational contents of health care professionals about HIV in counseling.
MATERIALS AND METHOD
This is a qualitative, descriptive-exploratory study, guided by the process approach of the Theory of Social Representations (TSR)13. It is in accordance with the COREQ guide. Developed in the municipalities of Recife and Jaboatão dos Guararapes, Pernambuco, Brazil, selected due to the annual number of new HIV cases per residence in relation to other municipalities in the state, in the period from June 2017 to February 2018.
As for technological density, the scenarios included were eight Basic Health Units (BHU), two Emergency Care Units (ECU), two polyclinics, two Counseling and Testing Centers, three hospitals, being two high-risk maternity hospitals and a general hospital, totaling 17 points in the health care network.
The sample was intentional, non-probabilistic, and consisted of 30 participants, included based on the following criteria: being a graduate health professional; being qualified for HIV testing and counseling; and acting as a counselor for six months or more. Those on leave of absence for more than six months and in exclusively administrative or managerial activities were excluded.
As for the instruments used for data collection, a semi-structured interview script was developed with guiding questions about HIV representations in counseling. Sociodemographic questionnaire with the variables age, sex, religion, profession, and length of professional experience as a counselor. And script for recording non-participant observation sessions in a field diary, with description of the environment in order to differentiate the situations in the levels of care and relationships between people involved, users, family members, partners and counseling professionals.
The data were collected by a doctoral student and two undergraduate nursing students trained and under supervision of the main researcher, leader of the research group, in rooms reserved in the participants' workplaces. All ethical aspects inherent to research with human beings were complied with. The researchers introduced themselves, explained the research objectives, and invited the professionals to sign two copies of the Informed Consent Form. There were seven refusals among the invited counseling professionals. After the pilot test, no need to modify the data collection instruments was identified.
As for the methods and techniques used to analyze the data, descriptive statistics with support from the Statistical Package for the Social Science (SPSS) version 22.0 were used for the quantitative data from the sociodemographic questionnaire.
As for the qualitative data, we obtained individual audio records of the interviews by digital recording in .mp3 format, with an average duration of 21 minutes. The participants could listen to the audios and decide on the exclusion of excerpts or the entire interview. Next, we transcribed the data, which underwent thematic-categorical content analysis, consisting of three stages14.
In the first of them, called pre-analysis, the corpus obtained from the transcriptions was organized and defined. This resulted in 56 pages of files in .docx format according to the requirements of the ATLAS.ti 8.0® software such as the adequacy of the text to the standard norm; verification of the concordance between the transcriptions and the recorded audios; and standardization of the nomination of the audio and text files with the professional category, attention point and Arabic numeral in order of interview, as in the example: Nurse BHU 14, saved in a specific folder for the inclusion of the project through the creation of the hermeneutic unit15.
Subsequently, the second stage began, material exploration or coding, in which excerpts from the interviews were grouped by selecting the text read and activating the command create quotes to identify units of meaning, registration and context. In the third stage, called results processing, inference, and interpretation, the categorization process was carried out, that is, the classification of the meaning units into certain categories. For this, readings of the data were done in order to identify patterns, which were incorporated into the descriptions of the thematic categories built, named, and presented using as a guide the theoretical reference of the study, the TSR13)(15)(16)(17. We tried to compose and associate for each verbal record, interview, action or practice the correspondence from the observations recorded in the field diaries13,15.
The study was conducted in compliance with the ethical aspects provided for in Resolution 466/2012 of the National Health Council (NHC). Evaluated and approved by the Research Ethics Committee (REC) of the University of Pernambuco, Hospital Complex - Hospital Universitário Oswaldo Cruz (HUOC)/ Pronto Socorro Cardiológico Universitário de Pernambuco - prof. Luiz Tavares (PROCAPE), Pernambuco, Brazil, CAAE 79852217.6.0000.5192 and opinion no. 2,431,472.
RESULTS
The participants of this study have a mean age of 48 years, ranging from 26 to 67 years; 80.70% are female; 46.88% are nurses, 28.12% physicians, 15.62% social workers and 9.38% psychologists. Regarding the time they have been working in HIV counseling, it was from 9 months to 24 years, with an average of 12 years as counselors. From the analysis supported by the ATLAS.ti 8.0® software, it was possible to select 519 RU (Registration Unit) from the 30 interviews, called primary documents, from which three thematic categories emerged, presented below.
Social prejudices that compromise the confidentiality and privacy in the reception
This category includes the HIV representational contents related to the social prejudices observed in the RU of the counseling professionals of the BHU about the stigmatizing designations attributed to the virus and the disease.
[...] the primary issue is the prejudice of the community as a whole... and the lack of information of the patients... of the people who have the disease... and oh: nobody wants to tell the other that the person has an HIV diagnosis [...] there are still many stigmas about it... the difficulty is this... because of the prejudice and the fear that the patient has of dying because of it [...] (Physician BHU 23)
As for the practices, the difficulties in ensuring privacy, confidentiality, and anonymity of the user stood out. These difficulties were expressed in the reception, counseling, and care by referral from testing reference services and support services that form the proposed health care network, in a comprehensive HIV care line, although the greatest difficulty observed was in the reception practices.
The following RU addresses the health communication practices related to HIV diagnosis, reception, testing and counseling, which should take place in a place close to the user's residence, preferably at the BHU. However, the participants of this study pointed out that this proximity to the user's place of residence can generate discomfort and distrust regarding the service and the ability to maintain confidentiality by the health team in front of the community, in an attempt to welcome them:
[...] then usually when the test [...] is positive we call the community health agent and communicate the seropositivity to the health agent [...] we ask him not to comment to anyone else (Nurse BHU 13)
Prior communication between members of the multiprofessional health team can be experienced in the reality of primary health care (PHC) as a proposed practice for the formation of the bond, as a tool to get to know the user better and get closer to him. However, in some respects it reinforces expectations about the difficulty in maintaining secrecy and privacy.
Both, secrecy, and privacy, were pointed out as necessary to the professional performance to communicate and advise in the BHU, right at the reception. The RU below highlighted the recognition of the importance of both for quality care and assistance in the PHC:
Secrecy... privacy [...] because many times he ((patient with reactive result)) doesn't want to tell that professional ((health professional)) that he is a sex worker... he doesn't want to talk about his homosexuality because of his privacy... so this will make us turn on our lights so we can achieve a greater goal [...] (Nurse BHU 11)
However, building this bond represents a challenge when faced with the prospect of sharing information about patients with other members of the multidisciplinary team, before performing post-test counseling in reactive cases, but it does not appear as a concern for pre-test counseling. Therefore, it is analyzed that the embracement practices in the BHU are only activated in situations where the user has already been tested and is reagent.
Vulnerabilities that consolidate pre-test counseling
It reveals other marked differences between the representational contents of HIV and counseling practices in primary health care (PHC) and secondary health care (SHC). While confidentiality in PHC is compromised, anonymity is the element that makes SHC eligible for the general population. This is the case of the health care point, called HCP, where anonymity is the main responsible for the great demand by users who wish to know their serological status and who do not fit profiles already tested as “routine” in the BHU, in the Family Health Strategy (FHS), as pointed out by RU:
[...] we ask the family health strategy in our territory for pregnant women and people with tuberculosis... it's our routine... we ask routinely, it's standard procedure, unless the patient comes with complaints... but these are a small group (Physician FHU 10)
T
The HCP act offering testing and counseling with emphasis on pre-testing, while in the BHU, the serological test is performed and only after the interpretation of a reactive result is that the counseling begins. In this case, the reception is employed as a practice of support or emotional stabilization, or of bond building for treatment adherence. The RU expressed the importance of pre-testing as a practice related to the representational content of HIV as vulnerabilities in HCP:
[...] PRE-TEST is very important... I think there are some lines of work that think that this pre-test counseling is not so important... but it is there that we make the user come into contact with that demand that brought him... learn about the depth of the test [... ] if he doesn't go through the pre-test the delivery of the result is more complex... because it is as if the first moment he makes a questioning about whether there is a possibility or not ((vulnerability))... prevention was done... it wasn't? when he does the exam the delivery of the result is much more guided by the pre-test [...] (Social Worker HCP 01)
The HCP professionals participating in the study highlighted the great importance of self-knowledge or recognition of individual and social vulnerabilities for the adoption of preventive measures by users when non-reactive and to reduce the negative impacts of post-testing in reactive cases. The action of professionals in the practice of counseling, as described by the RUs below, consists of resuming the content about vulnerabilities and risks addressed in the pre-test, bringing to mind what led up to that moment and, therefore, what needs to be changed whether the patient is reactive or not in the post-test:
[...] let's talk about risks again... go back to what was said in the pre-test... why did you (do the test)? so you had that risk now let's stop and evaluate it properly [...] (Social Worker HCP 02)
[...] as we do a pre-test, and it is a characteristic of mine, I make from the pre-test to a post-test... so if in the pre-test he talks about a risky situation he had I will start the post-test result "-we have already talked about a risky situation you had..." from there we enter the question of the result [...] (Psychologist HCP 05)
The representational contents of HIV related to vulnerabilities in the conception of key or priority populations, or even risk behaviors, also seem to be more recurrent among HCP professionals:
[...] today are people with more vulnerabilities... many times... it is a person that is itself the synthesis of multiple social problems... a person that is at the poverty level... no income... so... he/she already has many problems [...] this person already brings a load of very serious social issues [...] (Social Worker HCP 06)
The practices, in this point of care, blur the usual centrality of the biological aspects in health, which reveals that, for this reason, it matters less if the user reacts or not, but if he/she can recognize him/herself as someone vulnerable to HIV and that he/she can change his/her attitude about prevention and treatment after being tested, reaffirming the focus on health promotion, and not on getting sick:
[...] the biggest difficulty when a good pre-test is not done... when you don't have that pre-test is that you can be guiding that person about the risks they took... of the possibility of yes... of being positive... work this out before [...] (Social Worker HCP 01)
However, the HCP is not the only point of care at this level where health communication related to HIV diagnosis takes place, the polyclinics and the CHUs perform reception, testing and counseling practices. In the case of Recife, the HCP operates within the physical structure of a polyclinic, and in Jaboatão dos Guararapes, users with indeterminate or reactive results are referred for consultation with an infectious disease specialist in a polyclinic.
As for the ECU, it is emphasized that it is a point of SHC in view of the assessment of the technological density that it should cover, however it has acted as inpatient units and offered high complexity services, in view of the care flow in the network of urgencies in Brazil and the needs of the community where it is inserted, so its practices are more similar, in some moments identified in this study, to those of points of tertiary health care (THC).
Serologic condition and treatment that make testing urgent
The analysis reveals the urgency of confirming a clinical case in the counseling practices of these health care points, consisting of RU in which testing with a sense or function of confirming the serological condition in the face of a clinical or epidemiological suspicion stands out:
[...] one of them was an abscess that perforated... when we drained it, it was in an emergency, it drained several times... and then he had to be hospitalized... to do venous antibiotics... and then within the diagnostic investigation we asked for anti-HIV [...] (Physician Hospital 21)
[...] it is important to do a complete anamnesis... involving the patient's past [...] a case that I followed in an ECU that the patient must have been about 30 years old with a very widespread scabies and he came to the emergency [...] seeing the clinical picture... we requested the rapid test for HIV and this test was positive... with the result of this test we first called the patient to communicate him and make the appropriate referrals [...] (Physician 17 ECU)
In this context, in the general hospital and in the ECU, testing is part of the clinical investigation, useful for confirmation of HIV serological status and guidance on the conducts for initiation of antiretroviral therapy in the practices, which refers to other representational contents of HIV in THC besides the one related to serological status, those related to treatment.
In the context of THC, health communication related to HIV diagnosis does not occur in only one point of care, but in general hospitals, ECU, and maternity hospitals, and despite the differences related to physical structures and health team composition, testing practices are carried out with a certain degree of urgency for the confirmation of the serological status throughout THC, almost always directed or oriented to other actions related to the immediate initiation of drug treatment in the face of aggravation caused by opportunistic diseases.
As for counseling practices in maternity hospitals, the study participants revealed that the urgency of the moment makes it difficult to perform counseling properly:
[...] I have worked in a maternity hospital for many years... we receive users there ((institution name excluded)) who do the test during pregnancy... at the time of delivery and find out they are HIV positive... we came into contact with this reality of talking, counseling, referring (Psychologist Maternity 27)
[...] there was a situation of a puerperal woman... in the immediate postpartum... that I remember... she did her 20 rapid test and had a reaction [...] it was a really delicate situation... it was right in the immediate postpartum and there is still the issue of breastfeeding... of not being able to breastfeed her child (Nurse Maternity 15).
The gravid-puerperium cycle and childbirth, when added to health communication related to HIV diagnosis, involve essential issues of the family relationship and between mother and child with great potential for suffering. For professionals, breastfeeding is one of these critical moments.
DISCUSSION
In this study, it was found that nurses were the most present counseling professionals
of the multiprofessional team in the comprehensive HIV care line, which leads to the need to explore the practices of welcoming, testing, and counseling performed by nurses in the health care network, in order to support the work process or practices of these professionals.
Evidenciou-se a ampla experiência dos profissionais participantes do estudo no aconselhamento, o que permitiu conhecimento sobre relações entre as representações e práticas perante as constantes mudanças e transformações epidemiológicas, sociais e políticas.
As for the representational contents, it was identified that the first category revealed that PHC professionals present HIV as a phenomenon linked to social prejudices rooted in the social imaginary related to death. It is affirmed that these representations are in transformation of the resistant type, when even in contradiction with the previous representation, until then of the hegemonic type, it finds mechanisms to maintain some of its characteristics in the new representation16,18) that reveal not the fear of biological death, but of social death in the face of prejudice19.
In a study on the construction and transformation of social representations of AIDS and implications for health care, it was shown that over the decades the introduction of the possibility of living with the virus and the lessening of the importance of death have gained increasing prominence as a result of access to antiretroviral therapy16, a process called normalization of disease.
Among the findings of the present study, it is noteworthy that prejudice compromises confidentiality and privacy in the reception process, which are assured even in a perspective of reorientation towards PHC, of testing and counseling practices5. This is because these efforts were understood as a way to expand the offer only to specific populations, such as women in the gravid-puerperium cycle and patients under investigation for tuberculosis20,21.
The studies on the social representations of health professionals about HIV are loaded with conceptual dualities that interrelate common sense knowledge and reified knowledge17. When establishing the health communication process, the professionals project their beliefs, values, and opinions, even if unconsciously, revealing difficulties in dealing with the other's subjectivity, but they recognize that they must consider the user's beliefs and values to be effective in their attempt to promote an encounter and communicate, revealing the intersubjective aspect of health communication12,22.
Thus, in the second thematic category, the representational contents of HIV of SSA professionals reveal considerations related to vulnerabilities. These representations are considered as emancipated or in emancipation16, because they are produced in inter-group relations, by divergent groups, professionals, and users, and acquire autonomy when shared and appropriated by both, but can also be understood as intersubjective, i.e., dealing with the encounter between people23.
A interdependência, ou dependência mútua, afirmada neste estudo, entre os conteúdos representacionais e as práticas, permitiu compor outras considerações sobre a organização das práticas de aconselhamento. Admite-se a identificação de dificuldades entre os profissionais da PHC em garantir o sigilo e a privacidade, levando os usuários à procura de serviços com ênfase no anonimato durante o acolhimento, testagem e aconselhamento enquanto práticas dos THC.
Changes in the way of perceiving and integrating critical conditions and elements of vulnerability, such as gender, race, ethnicity, sexuality, social class, age group, and the effects they produce on interpersonal or intersubjective relationships23 in professional practice are aimed at improving health care19-24.
Studies from sub-Saharan African and Asian countries marked by vulnerabilities that threaten women and children, who are daily victims of sexual abuse and violence, argue that testing and counseling needs to address the different realities of people19,25. A study conducted in Mexico includes violence and immigration as critical elements26. And other studies from Latin America present data that reinforce the increased vulnerability to HIV among some specific populations, called key and priority populations27.
There is criticism of the bio medicalized actions between testing and treatment, demonstrating the increase in supply and diversity of tests and the reduction in importance of counseling28,29, revealing counseling in some other points of the attention network, characteristics of irreversible situations, those that are present in norms or rules of institutions and that pressure those involved to transform their representations due to the new proposed or even imposed practice28.
In another sense, in the third thematic category, the social representations of HIV refer to the normality of the epidemic in its only biomedical contexts, that is, serological. In this way, the practices converging in a relationship of interdependence with the representations in the HTA reveal the urgency in testing for confirmation of the serological condition, referral, and initiation of antiretroviral treatment in a situation of serious illness or worsening of the health condition or risk for vertical transmission,29 so that the immediate situation can be resolved.
This is because technological advances, both for detection and treatment, mark changes in health practices and policies, and relate to the transformation of representations of the resistant type28, those that are life-threatening to progressive transformation29, or those of the hope for normality based on pharmacological treatment. In other words, at this level of attention, the antiretroviral treatment is presented by the professionals as a possibility to revert the imbalance of the imminent health situation and only then can it be thought of under an educational perspective of adherence25.
It is worth noting that in African countries, in order to expand the diagnosis of HIV, testing is employed as a public health strategy without counseling. In this context, the test is not understood as a professional practice, lay people such as community leaders and volunteers trained for this purpose perform it during health actions and there is also the encouragement of self-testing for specific population groups30.
As a contribution to the advancement of scientific knowledge on the subject, the results may support the development of continuing education strategies for professional qualification and updating, aimed at implementing favorable conditions for HIV-related health communication, especially among nurses, considering that they are the professionals most integrated into the actions, strategies, and programs for testing and counseling in Brazil.
This should be performed from the perspective of health promotion and education, valuing the practices of welcoming, testing, pre-test and post-test counseling, observing the individual and social vulnerabilities, integrating all the potentialities of the health care network in a comprehensive HIV care line guided by the guarantee of privacy and confidentiality.
As for the limits of the study, these stem from the qualitative methodological approach, due to the fact that it does not allow generalizations of results. However, these limitations were circumvented by the possibility of comparability of results with other studies using the theoretical framework of social representations to understand a complex phenomenon of importance to health promotion.
CONCLUSION
The study analyzed the representational contents of health care professionals about HIV in counseling and showed that the circumstances of the situation differ according to the contexts and levels of health care. Furthermore, practices are also influenced and transformed by these representations, as much as the reverse is also true. Even in institutionalized settings, intersubjectivity also seemed to have a relationship with their representations and practices, and therefore can interfere with the way health communication happens.
Health communication practices related to HIV diagnosis in PHC are convergent and did not vary much in each point of care of the same type, the BHU. However, the relationships between social representations of HIV and practices are divergent and subjective. As for SHC, although convergence and clear intersubjectivity are evident in the HCP and a little less obvious in the polyclinic, it is considered that there are divergences between representations and practices, this because, at this level, the points of care are diverse, highlighting the BHU that acts more closely to the practices of the THC in which there is convergence between practices and representations of counseling professionals from maternity hospitals and general hospital.
It is considered that health communication related to the diagnosis of HIV should be guided by the perspectives of health promotion and network health care, so that its intersubjective aspects, i.e., the encounter between subjects in different contexts, denote a possible challenge for health professionals and nursing, so that it is expected with this study to subsidize the professional practice by promoting favorable conditions for health communication. As for the implications for nursing, the study provides directions and actions that enhance the appropriate professional performance, consequently improving the assistance to people. In order that the understanding of intersubjective aspects may subsidize favorable conditions in counseling at all points of the health care network.
Acknowledgements
The present work was carried out with the support of the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - Brazil (CAPES) - Funding Code 001, in the modality of doctoral scholarship , granted to Amanda Regina da Silva Góis, in the period from 2015 to 2018.
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Received: February 10, 2022; Accepted: June 29, 2022