Fear of Stigmatization and Lack of Confidentiality

Ene
FEAR OF STIGMATIZATION AND LACK OF CONFIDENTIALITY AS FACTORS
AFFECTING VOLUNTARY COUNSELING AND TESTING SERVICES IN
BRAITHWAITE MEMORIAL SPECIALIST HOSPITAL, PORT HARCOURT.

BY

ENE PETER, JANET

Department Of Human Kinetics and Health Education, Faculty of Education, University Of Port
Harcourt, Port Harcourt, Rivers State, Nigeria.

Abstract
Voluntary Counseling and Testing (VCT) is an essential component of comprehensive AfDS
prevention and treatment programmes. VCT enables people to learn their HIV status in the most
informed and supportive way possible. Counseling is done before the test to educate them about
HIV infection and afterward to help them respond appropriately to the results. The study
investigated the effects of stigmatization and lack of confidentiality on voluntary counseling and
testing services in Braithwaite Memorial Specialist Hospital (BMSH), Port Harcourt Rivers State.
The sample size consisted of 100 health personnel and non health personnel drawn from the VCT
centre BMSH Port Harcourt Rivers State using simple random sampling technique to compute
the sample size. Cross-sectional descriptive survey design was adopted for the study. Two
research questions were answered. Questionnaire was used for data collection, a modified iikert
scale of, agree and disagree was used. It was validated by the researcher's supervisor and two
other lecturers in the School of Public Health Nursing Port Harcourt. Split half method was used
to determine the reliability of the instrument and reliability co-efficient on full test of 0.69 was
obtained. Data obtained was analyzed using the descriptive statistics of frequency distribution
tables, percentages and graphs for demographic data and to answer research question. The result
showed that all the variables investigated do not affect VCT services in BMSH Port Harcourt. It
was recommended among others that massive awareness and enlightenment campaign by
governmental and nongovernmental organization should continue and be sustained so that the
gains of previous campaigns would be consolidated.

Background to the Study

In 2007, it was estimated that 33.2 million people lived with the disease worldwide, and that AIDS
killed an estimated 2.lmillion people including 330,000 children and over three quarters of these
deaths occurred in Sub-Saharan Africa (WHO, UNAIDS Report, 2007). According to Wigley
(2004) Voluntary Counseling and Testing (VCT) is an essential component of comprehensive
AIDS prevention and treatment programmes. VCT enables people to learn their HIV status in the
most informed and supportive way possible. Counseling is done before the test to educate them
about HIV infection, and afterward to help them respond appropriately to the results. Wigley
(2004) states further that VCT thus serves as an entry point to services that promote health and

African Journal of Professional Research in Human Development in Africa, Vol. 8, No. 4, December, 2012
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risk reduction. Those who test negative receive prevention counseling and those who test positive
receive referrals to prevention, care, support and treatment programs. VCT also encourages and
provides support for disclosing one's HIV status to sexual partners. Reports by UNGASS, (2010)
show that Nigeria has an estimated 3.6 percent of its population living with HIV and AIDS. Fear
of Stigmatization and Lack of Confidentiality
Although HIV prevalence is much lower in Nigeria than in other African countries such as South
Africa and Zambia, the size of Nigeria's population (around 149 million) meant that by the end of
2009, there were almost 3 million people living with HIV (UNGASS Report, 2010). Furthermore,
the UNGASS Report posits that approximately 192,000 people died from AIDS in 2009. With
AIDS claiming so many lives, Nigeria's life expectancy has declined significantly. World Health
Organization (WHO), (2008) reports that in 1991 the average life expectancy was 54 years for
women and 53 years for men. In 2009, these figures had fallen to 48 for women and 46 for men
(CIA, 2010). Nigeria has a national prevalence of 5.8%. Abuja's rate grew from 7 to 10% from
1999 to 2001 due to ignorance about personal risk of HIV and of benefits of Voluntary Counseling
and Testing (VCT). There is no standard VCT centre in the city. Available testing services may
be coercive, costly or lack strict confidentiality, increasing fear of stigma and beneficiaries include
migrant workers, traders, motorist, tourist, sex workers and pregnant women in the city (Centre
for the Right to Health, 2010). Wigley (2004) also notes that in 1993, Family Health
International (FHI) supported two on-going VCT sites in Nigeria through its USAIDFunded
Impact Project. These two centres in Lagos and Kano were the first stand alone VCT facilities in
Nigeria. The Lagos center is operated by the Salvation Army, a global philanthropic organization
that has worked with the Nigerian government on AIDS programs since 1992, with plans to
expand to 22 sites in 2004. However VCT centers have opened up in teaching hospitals, specialist
hospitals and other specially designated sites all over the country today. Studies on HIV voluntary
counseling and testing in developing countries to prove the efficacy and cost effectiveness of
providing voluntary counseling and testing for HIV-1 in developing countries were reported in
the new issue (July 8, 2000) of the British Medical Journal - The Lancet. The efficacy study,
headed by Thomas J. Coates, director of the AIDS Research Institute at the University of
California, San Francisco, enrolled 3,120 individuals and 586 couples in Nairobi, Kenya, Darees
Salam, Tanzania, and Port-of-Spain Trinidad.

Statement of the Problem

VCT is when a person chooses to undergo HIV and AIDS counseling so that they can make an
informed decision about whether to be tested for HIV. VCT is an HIV intervention/prevention
strategy to reducing the burden of HIV and AIDS. It is also being recognized as an entry point to
care and support as well as being an essential tool for behaviour change for people who test both
HIV positive and HIV negative, hence contributing toward reduction of stigma. At the end of
2002, an estimated 42 million people globally were living with HIV, most of whom did not know
they carry the virus, while those not yet infected knew nothing or too little about HIV to protect
themselves. While about one third of those currently living with HIV and AIDS are aged 15-24
years. Young women continue to be more vulnerable to HIV than their male counterparts. Sub-
Saharan Africa is the most affected by HIV and AIDS. The region has less than 10% of the world's
population, yet is home to almost 70% of the people living with HIV and AIDS. VCT provides
important information about a person's sero-status and encourages reduction of risk behaviour
while at the same time assisting with linkages to medical care. However, studies and reports show
that some VCT centers are riddled with problem which include amongst others, youth

African Journal of Professional Research in Human Development in Africa, Vol. 8, No. 4, December, 2012
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unfriendliness, coercive, high cost or lack strict confidentiality and increasing Fear of
Stigmatization and Lack of Confidentiality

fear of stigma. The problem of this research therefore, is to investigate the impact of stigmatization
and lack of confidentiality on VCT services in Braithwaite Memorial Specialist Hospital (BMSH),
Port Harcourt.

Purpose of the Study

The aim of this study is to investigate the impact of stigmatization and lack of confidentiality on
VCT services in Braithwaite Memorial Specialist Hospital (BMSH), Port Harcourt.

Specific Objective of the Study

Specifically, this study intends to find out whether.
i) Fear of stigmatization is a factor affecting voluntary counseling and testing services
in Braithwaite Memorial Specialist Hospital, Port Harcourt.

ii) Lack of confidentiality is a factor affecting voluntary counselingand testing

services in Braithwaite Memorial Specialist Hospital, Port Harcourt.

Research Questions
The following research guestions were formulated to guide the study.
1. Is fear of stigmatization a factor affecting voluntary counseling and testing services in
Braithwaite Memorial Specialist Hospital, Port Harcourt?

2. Is lack of confidentiality a factor affecting voluntary counseling and testing in Braithwaite

Memorial Specialist Hospital, Port Harcourt?

Definition of Terms (Operational)

Voluntary: This is when an individual willing opts to go for the counseling and testing.
Counseling: This is when professionals provide information about HIV/AIDS and testing and
help people to accept to be tested or not. Also, the counselor assist in what to do after the result
of the test is ready.

African Journal of Professional Research in Human Development in Africa, Vol. 8, No. 4, December, 2012
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Testing: This is laboratory examination of blood specimen of people to show if Human Immuno
Virus is present or absent in it.
Fear of Stigmatization and Lack of Confidentiality

Review of Related Literature

HIV/AIDS
According to Basavanthappa (2008), Amadi (2002) and Lucas and Gilles (2003), AIDS, the
Acguired Immuno-Deficiency Syndrome (sometimes catted "slim disease, Basavanthappa, 2008)
is a newly described, usually fatal illness caused by a retrovirus known as the Human
Immunodeficiency Virus (HIV) which breaks down the body's immune system leaving the victim
vulnerable, to a host of life threatening opportunistic infections, neurological disorders, or unusual
malignancies.

Origin
Infectious diseases had ceased to be a major problem in developed countries till a decade or two
ago but with the advent of AIDS in the early 80's, the situation changed dramatically. Retro-virus
and their cancer causing potential are not new to scientists. Reverse transcriptase was discovered
in 1970. However, up to mid 70s another infectious retrovirus was found in human beings. In
1980, the first human retrovirus HTLV-1 was isolated which causes a rare, highly malignant
cancer called adult and T-cell leukemia, that is endemic in parts of Japan, Africa and Caribbean
islands and spreading to other regions as well, two years later, HTLV-2 was found out. Both
viruses cause immune depressions and therefore, when AIDS cases were first discovered, the
initial hypothesis was that the cause of AIDS could be a close reactive of HTLV1, the hypothesis
did not prove correct, however, the search in this direction led to the discovery of HIV as the cause
of AIDS (Basavanthappa, 2008).

African Journal of Professional Research in Human Development in Africa, Vol. 8, No. 4, December, 2012
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Fear of Stigmatization and Lack of Confidentiality

Goals of Voluntary Counseling and Testing (VCT)

• Generally, VCT aims at reducing spread of HIV; mitigating its impact; reducing fear &
anxiety associated with HIV testing; improving the length & quality of lives of those who test
positive by linking them to treatment, care & support services; and reducing HIV stigma. Get
information and counseling on how to live positively with the virus. This means learning to
accept the fact that the individual is HIV-infected, seeking emotional support, eating a healthy
diet, learning how to control the amount of stress in their lives, making sure he or she does
not become re-infected, and planning for the future.

• Learn to recognize the signs of opportunistic infections so individuals can get treated
promptly.

• Find out what resources are available within the community to help people manage their HIV
status.

• Find out about prophylactic drugs. These drugs do not cure HIV/AIDS, but can prevent the
individual from getting some opportunistic infections that are common with people living
with HIV/AIDS, for example, tuberculosis and some kinds of pneumonia.

• Access Nevirapine. This is a drug available at a number of hospitals and clinics that lessens
the chance of a pregnant mother passing the virus onto her baby.

• Get emotional support by seeking counseling and joining support groups.

• Make sure that they do not infect anyone else or get re-infected themselves.
• Learn how to manage the stress in their lives.

VCT can motivate those who are not infected with HIV to stay HIV antibody negative, and to
accept those who are infected (Angaza Project Tazania, 2001). Angaza Project Tazania, (2001)
notes the following about voluntary counseling i-n HIV and AIDS.

Pre-Test Counseling:
This is the kind of counseling done before an individual decides whether they want to have the
HIV antibody test. Some of the issues the counselor will discuss with the individual are:

• Why the individual decided to come for counseling.

• What counseling is and the role of the counselor.

African Journal of Professional Research in Human Development in Africa, Vol. 8, No. 4, December, 2012
• The individual's personal history.
• Whether the individual has any health problems.
• What the individual's risk of being HIV infected is.
• What the individual knows about HIV/AIDS.

Revised Guidelines for HIV Counseling, Testing, and Referral. Technical Expert Panel
Review of CDC HIV Counseling, Testing, and Referral Guidelines, (1999).

A review of these guidelines is necessary because other countries adapt their VCT guidelines based
on it. It presents a more elaborate discussion of all that VCT entails. These guidelines replace
CDC's 1994 guidelines, HIV Counseling, Testing, and Referral Standards and Guidelines, and
contain recommendations for public- and private-sector, policy makers and service providers of
human immunodeficiency virus (HIV) counseling, testing, and referral (CTR). To develop these
guidelines, CDC used an evidence-based approach advocated by the U.S. Preventive Services
Task Force and public health practice guidelines. The recommendations are based on evidence
from all available scientific sources; where evidence is lacking, opinion of "best practices" by
specialists in the field has been used. This revision was prompted by scientific and programmatic
advances in HIV CTR, as well as advances in prevention and the treatment and care of HIV-
infected persons. These advances include; a) demonstrated efficacy of HIV prevention counseling
models aimed at behavioral risk reduction; b) effective treatments for HIV infection and
opportunistic infections; c) effective treatment regimens for preventing perinatal transmission; and
d) new test technologies. Although the new guidelines include many aspects of the previous ones
(for example, encouragement of confidential and anonymous voluntary HIV testing, need for
informed consent, and provision of HIV prevention counseling that focuses on the client's own
risk), the new guidelines differ in several respects, including

• giving guidance to all providers of voluntary HIV CTR in the public and private sectors;

• using an evidence-based approach to provide specific recommendations for

CTR;
• underscoring the importance of early knowledge of HIV status and making testing more
accessible and available;

• acknowledging providers' need for flexibility in implementing the guidelines, given their
particular client base, setting HIV prevalence level, and available resources;

African Journal of Professional Research in Human Development in Africa, Vol. 8, No. 4, December, 2012
• recommending that CTR be targeted efficiently through risk screening and other strategies;
and

• addressing ways to improve the quality and provision of HIV CTR.

Research Methodology
Research Design
The design of the study was cross-sectional descriptive survey. Cross sectional descriptive survey
design was used in this study to investigate the socio-economic factors affecting voluntary
counseling and testing (VCT) services at the Braithwaite Memorial Specialist Hospital, Port
Harcourt. The design was considered appropriate for this study because the researcher seeks to
collect data once from a sample drawn from the study population for a short period and describe
certain features of the sample. The thrust here is that certain features of the variables under
investigation in the study are merely described as they are at that particular time and the findings
from the sample are generalized to the population from which the sample are drawn.

Area of the Study

Braithwaite Memorial Specialist Hospital is a Rivers State government owned Specialist Hospital
located in Old GRA, Port Harcourt. It is the only health facility in the state with the status of a
specialist hospital. The VCT centre in this hospital is located in the General Out Patient
Department (GOPD).

Population of the study

The population for the study consisted of all the health personnel in the HIV/AIDS clinic and
laboratory services, and clients at the Braithwaite Memorial Specialist Hospital, Port Harcourt.

Fear of Stigmatization and Lack of Confidentiality Ene

Sample and Sampling Technique

Simple random sampling technique (using random numbers) was used to select a sample size of
about 50 respondents from the members of staff of the clinic and clients.

Instrument for Data Collection

African Journal of Professional Research in Human Development in Africa, Vol. 8, No. 4, December, 2012
A self developed, structured and validated questionnaire constituted the major instrument for
gathering data in this study. The questionnaire was in a modified Likert format of agree and
disagree. The questionnaire was made up of two sections, A and B. Section A addressed the
demographic data which includes sex, age, educational qualification of health personnels and non
health personnels, while section B addressed the variables under study.

Validity of Instrument
In order to ensure the face and content validity of the questionnaire, a draft of the questionnaire
was given to the researcher's supervisor and two other lecturers of the School of Public Health
Nursing, Port Harcourt. To ensure the effectiveness of this exercise, the researcher provided the
lecturers with clear guidelines on what to do in a letter that accompanied the questionnaire. The
purposes of the study as well as the research questions of the study were included. This helped the
lecturers to determine which items actually elicited the information they were intended to elicit.
In addition to this, there was 'specific instruction' to the lecturers to review the items in terms of
their clarity, appropriateness of the language and expression to the respondents, including the
appropriateness of the instruction to the respondents. At the end of questionnaire, space was
provided for comments the lecturers may wish to make regarding the overall adequacy of the
instrument. Thereafter, the items were modified along the lines suggested by the comments of
these lecturers and thus adjured to be valid.

Field Testing of the Instrument

The researcher carried out field testing of the instrument by administering the questionnaire to 10
respondents at the Family Medicine Department of Braithwaite Memorial Specialist

Hospital. This group was not used in the final study. Information received from the
Fear of Stigmatization and Lack of Confidentiality Ene
responses was used for modification of the questionnaire items and to improve the reliability of
the research instrument. The field test was also meant to acquaint the researcher on what possible
problem that may likely be encountered during the distribution and collection of data from the
respondents.

Reliability of Instrument
Reliability for internal consistency of the instrument was done using Split Half method. For this
purpose, the 10 questionnaires served to the General Outpatient (GOPD) Department of
Braithwaite Memorial Specialist Hospital were also used. These were retrieved after being filled

African Journal of Professional Research in Human Development in Africa, Vol. 8, No. 4, December, 2012
for calculation. The 10 questionnaires retrieved were split into two equal halves of odd and even
numbers. These were coded and first correlated using Pearson Product Moment Correlation
Coefficient. Then, the reliability on full test was done using Spearman Brown formula; rf = 2*
reliability on half test/ 1+ reliability on half test, rf = 2* r V2 / 1+ r Vi.

The reliability of the entire instrument was 0.69. The Reliability Coefficient value so obtained was
high enough to guarantee the use of the instrument for this study.

Procedure for Data Collection

The researcher got a letter of identification from the Principal School of Public Health Nursing,
Port Harcourt to the area of study. The researcher administered copies of the socioeconomic
factors affecting voluntary counseling and testing (VCT) services directly to the respondents
through personal contacts. The researcher was assisted on this by using the services of one research
assistant to ensure that the questionnaire were properly served on the respondents and retrieved.
Instructions pertaining to the filling of the questionnaire were thoroughly explained to the
respondents. The questionnaire were administered and retrieved immediately after filling. A total
of 100 questionnaires were served on 100 respondents used for the study and 78 were retrieved
after filling.

Procedure for Data Analysis

Data for this study was analyzed using Statistical Package for Social Sciences (SPSS) version 14.
They were analyzed according to the research questions. Also, data collated on agree and disagree
dichotomous format was analyzed using descriptive statistics of Fig. 1: A Bar Chart Showing
the Distribution of

frequency distribution table, and graphs percentages for demographic data and to answer the
research questions .

Data Analysis and Interpretation

Section A: Demographic data of Respondents
Table 1: Gender Distribution of the Respondents in Percentage
Gender Frequency Percentage
Male 30.00 38.00
Female ,48.00 68.00

African Journal of Professional Research in Human Development in Africa, Vol. 8, No. 4, December, 2012
 Total 78.00 100.00

Fig 1: Bar Chart Showing the Distribution of the

Respondents based on Gender

70
60
50
40
30
20
10
0
Male Female

Gender
Frequency

Percentage

Table 1 / Figure 1 present the gender of the respondents. It shows that the male respondents were
30 in number which is 38% of the entire sample size while the female respondents were 48 in
number, representing 68 % of the sample size. This indicates that there were more females than
males respondents in the sample of investigation.

Table 2: Age Distribution of the Respondents in "Percentage"

Age range ( in years) Frequency Percentage
18-22 years 10.00 13.00
23-27 years 18.00 23.00
28-32 years 16.00 20.00
33-37 years 14.00 18.00
38-42 years and above 20.00 26.00
Total 78.00 100.00

Fig 2. A Bar Chart Showing the Distribution of the Respondonts

based on Age

African Journal of Professional Research in Human Development in Africa, Vol. 8, No. 4, December, 2012
 30

25

20

15

10

0
18-22 23-27 28-32 33-37 38-42 and
above
Age

Frequency
Percentage

Table 2 / Figure 2 show the age distribution of the respondents as well as the percentage they
represent in the sample. It can be seen that the age bracket of 38- 42 and above appeared most in
the sample with 26% that is to say that the majority of the respondents are experienced and can
give some reliable information to enable this investigation, while respondents within the age range
of 18-22 were the least in the sample with a percentage of 13%.

Table 3: Educational qualification of Respondents

Qualification Frequency Percentage
Secondary 40.00 49.00
Tertiary 38.00 51.00
Total 78.00 100.00"

Fig. 3. A Chart Showing the Distribution of the Respondents

African Journal of Professional Research in Human Development in Africa, Vol. 8, No. 4, December, 2012
 based on Qualification

60

50

40

30

20

10

0
Secondary Tertiary
Qualification Frequency
Percentage

Table 3 / Figure 3 show the distribution of the educational qualifications of the respondents, it can
be observed from the table that most of the respondents had secondary education (51%) and the
rest tertiary education (49%). The disclosed information about the respondents' qualification and
age attests to the fact that reliable information could be gotten from them to facilitate this
investigation.

Table 4: Respondents Status – Health Personnel or Non Health Personnel

Status Frequency Percentage

Doctors 8.00 10.00
Nurses 10.00 13.00
Laboratory Staff 6.00 7.00
Counselor 2.00 3.00
Others 2.00 3.00
Clients 50.00 64.00
Total 78.00 100.00

Fig. 4. A Bar Chart Showing the Distribution of the Respondents based on status

African Journal of Professional Research in Human Development in Africa, Vol. 8, No. 4, December, 2012
 (health personnel or client)

70
60

50

40

30
20

10

0
Doctors Nurses Laboratory Counselor Others Clients
Staff
Status (Health personnel or client) Frequency

Percentage

Table 4 / figure 4 indicate that the majority (64%) of the respondents was clients, and (13%)
nurses. This is very encouraging in this study because it is usually quite difficult to get clients
in VCT centres to respond to interviews or fill out questionnaires due to fear of stigmation if
their identity is revealed. In this case however, they had to be reassured of anonymity, and that
it is to generate data that will be used to improve services in the centre.

Section B: Answers to Research Questions

Research Question 1: Is fear of stigmatization a factor affecting VCT services in BMSH,
Port Harcourt?

Table 5: Percentage responses on fear of stigmatization as a factor affecting VCT services

in BMSH, Port Harcourt.
S/N Items AGREE DISAGREE TOTAL
(%) (%)
1 Voluntary counseling and testing is a useful 78(100.00) 78
tool in HIV and AIDS care and prevention
strategies.

African Journal of Professional Research in Human Development in Africa, Vol. 8, No. 4, December, 2012
 2 Many clients have learnt of their HIV and 58(74.36) 20(25.64) 78
AIDS status through voluntary counseling
and testing (VCT) services in this centre.

3 Response of the public to voluntary 24(31.16) 53(68.83) 77

counseling and testing (VCT) services in
this centre is unsatisfactory.

4 Only patients referred by doctors in the 26(33.33) 52(66.67) 78

hospital or from outside hospitals and
clinics are counseled and tested in this
centre.

5 Fear of stigmatization has limited the 39(50.00) 39(50.00) 78

response to voluntary counseling and
testing (VCT) services in this centre.

6 This has resulted in unsatisfactory 35(44.45) 42(54.54) 77

patronage of voluntary counseling and
testing (VCT) services in this centre.

N=78 %): percentages (fraction in parentheses)

Table 5 shows that the all (100.00% ) respondents indicated that VCT is a useful tool in HIV and
AIDS care and prevention strategies, many clients learnt of their HIV status in the centre and that
not only patients from the hospital were counseled and tested in the centre. They were undecided
in their responses that fear of stigmatization has limited the response to voluntary counseling and
testing (VCT) sen/ices in this centre. Also they (54.54%) disagreed that fear of stigmatization has
resulted in unsatisfactory patronage of VCT services provided in the centre.

Research Question 2: Is lack of confidentiality a factor affecting VCT services in BMSH,

Port Harcourt?

Table 6: Percentage responses on lack of confidentiality as a factor

African Journal of Professional Research in Human Development in Africa, Vol. 8, No. 4, December, 2012
 AGREE (%) DISAGREE TOTAL
Items
(°/o)
7 This centre is open and so lacks privacy. 39(50.00) 39(50.00) 78

8 As a result, clients complain of lack of 26(33.33) 52(66.67) 78

confidentiality of their HIV status after
voluntary counseling and testinq (VCT)
in this centre.

9 Lack of confidentiality of client's HIV 26(33.33) 52(66.67) 78

status due to the public nature of this
centre has adversely affected this centre.

10 This has resulted in low patronage of this 20(25.64) 58(74.35) 78

centre.
N=78, (%): percentages (fraction in parentheses)
Table 6 indicates that the respondents were undecided that the VCT centre in BMSH, Port
Harcourt is open and so lacks privacy (as 50% of respondents agreed and 50% also disagreed)
and they disagreed that lack of confidentiality has resulted in low patronage of VCT services the
centre.

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