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Global Public Health: An International Journal for Research, Policy and Practice Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/rgph20
Infection control in home-based care for people living with HIV/AIDS/TB in South Africa: An exploratory study Olagoke Akintola
ab
& Lydia Hangulu
a
a
School of Applied Human Sciences, University of KwaZulu-Natal, Durban, South Africa b
Click for updates
Program in Policy Decision-making, Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, Canada Published online: 04 Apr 2014.
To cite this article: Olagoke Akintola & Lydia Hangulu (2014) Infection control in homebased care for people living with HIV/AIDS/TB in South Africa: An exploratory study, Global Public Health: An International Journal for Research, Policy and Practice, 9:4, 382-393, DOI: 10.1080/17441692.2014.895405 To link to this article: http://dx.doi.org/10.1080/17441692.2014.895405
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms &
Downloaded by [Duke University Libraries] at 21:11 03 January 2015
Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
Global Public Health, 2014 Vol. 9, No. 4, 382–393, http://dx.doi.org/10.1080/17441692.2014.895405
Infection control in home-based care for people living with HIV/AIDS/ TB in South Africa: An exploratory study Olagoke Akintolaa,b* and Lydia Hangulua a
School of Applied Human Sciences, University of KwaZulu-Natal, Durban, South Africa; Program in Policy Decision-making, Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, Canada
Downloaded by [Duke University Libraries] at 21:11 03 January 2015
b
(Received 13 June 2013; accepted 7 December 2013) The majority of HIV and AIDS patients in sub-Saharan African countries receive health care services at home. Yet research on infection control in home-based care settings is virtually non-existent. This study explored infection control practices in home-based care in a South African province with a high HIV/TB prevalence. We conducted interviews with 10 managers of home-based care organizations and 10 focus group discussions with 80 volunteer caregivers working in high HIV/TB prevalent communities in South Africa. Findings show that volunteers had insufficient training on infection control. Materials necessary for the maintenance of hygiene and protective equipment were in short supply and the protective equipment supplied was of poor quality. Home-based care patients lived in crowded and poor conditions, and family members were negatively disposed to the use of protective devices. Together, these factors put volunteers and family caregivers at risk of infection with HIV and TB. Health policy should address the training of volunteer caregivers and the regular supply of good quality materials to ensure effective infection control. It is also important to educate families on infection control. Finally, there is a need to integrate HIV and TB control at the community level. Keywords: home-based care; infection control; tuberculosis; HIV/AIDS; South Africa
Introduction The majority of HIV and AIDS patients in sub-Saharan African countries receive health care services in their homes (Akintola, 2008; UNAIDS, 2012). This is particularly true in South Africa, which has the largest number (5.6 million) of people living with AIDS in the world (UNAIDS, 2012). At the same time, South Africa has the highest incidence rate of tuberculosis (TB) patients in the world at 981/100,000 people and the highest rate of drug resistant TB in Africa (World Health Organization [WHO], 2012). The majority (65%) of TB patients are co-infected with HIV and a high number of TB patients have multi-drug resistant (MDR) and extensively drug resistant (XDR) TB (Gandhi, Moll, & Sturm, 2006; Gandhi et al., 2013; UNAIDS, 2012; WHO, 2012). The huge burden of AIDS on the public health system prompted the government to adopt a policy on homebased care for people living with HIV/AIDS (Department of Health [DOH], 2001). In South Africa, community-based care organisations facilitate the provision of care to the ill in many of the communities with high HIV prevalence. They make use of *Corresponding author. Email: [email protected] © 2014 Taylor & Francis
Downloaded by [Duke University Libraries] at 21:11 03 January 2015
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community members who receive training and volunteer their time to assist family caregivers in providing home-based care to the ill. These volunteers commonly known as community or volunteer caregivers constitute a cadre of community health care workers in primary health care (Akintola, 2011; Schneider, Hlophe, & Van Rensburg, 2008). Volunteer caregivers as well as family caregivers provide basic nursing care to patients including bed baths; oral hygiene; care of sores and wounds; changing of diapers; feeding; cleaning of vomitus; administering drugs and physical therapy (Akintola, 2011; Schneider et al., 2008). These activities could put them at risk of infection with HIV because they frequently require direct contact with HIV/AIDS patients and with their body fluids. In addition, volunteers could be at risk of infection with TB when exposed to air contaminated with Mycobacterium tuberculosis while providing care (Akintola, 2006; Cluver, Orkin, Moshabela, Kuo, & Boyes, 2013; WHO, 2012). Cluver et al. (2013) found severe TB symptoms among children who were exposed to patients’ sputum and phlegm. This suggests that they may have inhaled TB contaminated air while providing care. In order to reduce the risk of transmission of infections in health care settings, the World Health Organization (WHO) recommends the use of standard precautions (WHO, 2007). Standard precautions include practicing hand hygiene: washing of hands after all contacts with patients; using personal protective equipment, such as gloves, masks, aprons and boots; practicing respiratory hygiene and cough etiquette; ensuring proper waste disposal and the maintenance of a clean and safe environment (WHO, 2007). The implementation of infection control measures has been shown to reduce nosocomial transmission of infections in clinical settings (Joshi, Reingold, Menzies, & Pai, 2006). However, we know very little about whether and how infection control is carried out in home-based care, since research on infection control in home-based care for people living with HIV/AIDS/TB is virtually non-existent. Given the high prevalence and co-infection rates of HIV and TB, research on infection control in home based care could help inform policy on home-based care and TB control. Therefore, in this study, the first to our knowledge, we explore the practice of infection control in home-based care for people living with HIV/AIDS/TB in South Africa with a specific focus on the control of HIV and TB infections. Methods Study setting and context The study was conducted in one rural and nine semi-rural (townships) communities on the outskirts of Durban in the KwaZulu-Natal province of South Africa. These communities have care organisations providing home-based care to people living with HIV/AIDS/TB. KwaZulu-Natal has the highest HIV/AIDS prevalence of 39.5% and one of the highest rates of TB in the country (Gandhi et al., 2006; UNAIDS, 2012; WHO, 2012). There are a number of home-based care organisations working across the province with varying degrees of financial and material resources and training for their volunteers. Participants Participants comprised (1) home-based care (HBC) coordinators/project managers and (2) volunteer caregivers. One HBC co-ordinator/project manager each from 10 home-based care organisations was recruited to participate in the study. The organisations were selected purposively from a list of organisations to reflect the range of organisations working in different communities in the greater Durban area. The organisations also had
384
O. Akintola and L. Hangulu
Downloaded by [Duke University Libraries] at 21:11 03 January 2015
to consent to participate in the study. Incidentally, all the organisations were funded by the Department of Health and all provided basic nursing care to patients. We purposively selected volunteer caregivers providing care to patients. Each of the organisations convened meetings with all their volunteers to inform them about the study. Those who consented to participate in the study were recruited to participate in focus group discussions. Participants were recruited if they: were volunteer caregivers working with any of the care organisations; provided home care to someone with clinical AIDS; provided care for a minimum period of six months; and were willing to respond to questions about infection control practices in home-based care. A total of 80 volunteers participated in the study. Table 1 shows home-based care coordinators/project managers’ sociodemographic characteristics, while Table 2 shows volunteer caregivers’ sociodemographic characteristics.
Procedure We conducted a qualitative study among HBC coordinators/project managers and volunteer caregivers between July 2010 and September 2011. Ten HBC coordinators/ project managers (one per organisation) participated in in-depth interviews, which were held in their offices. The interviews were conducted using topic guides drawn in English. The topic guides contained topics such as sociodemographic information, training on infection control, the practice of infection control and the barriers to the practice of infection control. Most of the interviews were conducted in English by one of the authors, while a trained research assistant conducted interviews for those who preferred to be interviewed in IsiZulu, the native language of participants. The interviews were taperecorded and lasted between 40 and 50 minutes. One focus group was conducted in each of the 10 care organisations and each focus group consisted of 4 to 11 volunteer caregivers. Table 3 provides the number of volunteers who participated in focus group discussions from each care organisation. The focus groups were conducted in convenient private rooms provided by each of the care organisations. A focus group guide containing open-ended questions was drawn in English and translated to IsiZulu. The IsiZulu version was used to conduct focus groups with the participants. The focus groups were facilitated by a trained IsiZulu-speaking Table 1. Sociodemographic characteristics of home-based care coordinators/project managers. Item Gender Male Female Age (years) 44–49 50–55 56–61 62–67 Work experience (years) 5–8 9–12 13–16
Frequency 0 10 5 2 2 1 5 4 1
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Table 2. Sociodemographic characteristics of volunteer caregivers.
Downloaded by [Duke University Libraries] at 21:11 03 January 2015
Item
Frequency
Gender Male Female Age (years) 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 Care work experience (years)
Global Public Health: An International Journal for Research, Policy and Practice Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/rgph20
Infection control in home-based care for people living with HIV/AIDS/TB in South Africa: An exploratory study Olagoke Akintola
ab
& Lydia Hangulu
a
a
School of Applied Human Sciences, University of KwaZulu-Natal, Durban, South Africa b
Click for updates
Program in Policy Decision-making, Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, Canada Published online: 04 Apr 2014.
To cite this article: Olagoke Akintola & Lydia Hangulu (2014) Infection control in homebased care for people living with HIV/AIDS/TB in South Africa: An exploratory study, Global Public Health: An International Journal for Research, Policy and Practice, 9:4, 382-393, DOI: 10.1080/17441692.2014.895405 To link to this article: http://dx.doi.org/10.1080/17441692.2014.895405
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms &
Downloaded by [Duke University Libraries] at 21:11 03 January 2015
Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
Global Public Health, 2014 Vol. 9, No. 4, 382–393, http://dx.doi.org/10.1080/17441692.2014.895405
Infection control in home-based care for people living with HIV/AIDS/ TB in South Africa: An exploratory study Olagoke Akintolaa,b* and Lydia Hangulua a
School of Applied Human Sciences, University of KwaZulu-Natal, Durban, South Africa; Program in Policy Decision-making, Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, Canada
Downloaded by [Duke University Libraries] at 21:11 03 January 2015
b
(Received 13 June 2013; accepted 7 December 2013) The majority of HIV and AIDS patients in sub-Saharan African countries receive health care services at home. Yet research on infection control in home-based care settings is virtually non-existent. This study explored infection control practices in home-based care in a South African province with a high HIV/TB prevalence. We conducted interviews with 10 managers of home-based care organizations and 10 focus group discussions with 80 volunteer caregivers working in high HIV/TB prevalent communities in South Africa. Findings show that volunteers had insufficient training on infection control. Materials necessary for the maintenance of hygiene and protective equipment were in short supply and the protective equipment supplied was of poor quality. Home-based care patients lived in crowded and poor conditions, and family members were negatively disposed to the use of protective devices. Together, these factors put volunteers and family caregivers at risk of infection with HIV and TB. Health policy should address the training of volunteer caregivers and the regular supply of good quality materials to ensure effective infection control. It is also important to educate families on infection control. Finally, there is a need to integrate HIV and TB control at the community level. Keywords: home-based care; infection control; tuberculosis; HIV/AIDS; South Africa
Introduction The majority of HIV and AIDS patients in sub-Saharan African countries receive health care services in their homes (Akintola, 2008; UNAIDS, 2012). This is particularly true in South Africa, which has the largest number (5.6 million) of people living with AIDS in the world (UNAIDS, 2012). At the same time, South Africa has the highest incidence rate of tuberculosis (TB) patients in the world at 981/100,000 people and the highest rate of drug resistant TB in Africa (World Health Organization [WHO], 2012). The majority (65%) of TB patients are co-infected with HIV and a high number of TB patients have multi-drug resistant (MDR) and extensively drug resistant (XDR) TB (Gandhi, Moll, & Sturm, 2006; Gandhi et al., 2013; UNAIDS, 2012; WHO, 2012). The huge burden of AIDS on the public health system prompted the government to adopt a policy on homebased care for people living with HIV/AIDS (Department of Health [DOH], 2001). In South Africa, community-based care organisations facilitate the provision of care to the ill in many of the communities with high HIV prevalence. They make use of *Corresponding author. Email: [email protected] © 2014 Taylor & Francis
Downloaded by [Duke University Libraries] at 21:11 03 January 2015
Global Public Health
383
community members who receive training and volunteer their time to assist family caregivers in providing home-based care to the ill. These volunteers commonly known as community or volunteer caregivers constitute a cadre of community health care workers in primary health care (Akintola, 2011; Schneider, Hlophe, & Van Rensburg, 2008). Volunteer caregivers as well as family caregivers provide basic nursing care to patients including bed baths; oral hygiene; care of sores and wounds; changing of diapers; feeding; cleaning of vomitus; administering drugs and physical therapy (Akintola, 2011; Schneider et al., 2008). These activities could put them at risk of infection with HIV because they frequently require direct contact with HIV/AIDS patients and with their body fluids. In addition, volunteers could be at risk of infection with TB when exposed to air contaminated with Mycobacterium tuberculosis while providing care (Akintola, 2006; Cluver, Orkin, Moshabela, Kuo, & Boyes, 2013; WHO, 2012). Cluver et al. (2013) found severe TB symptoms among children who were exposed to patients’ sputum and phlegm. This suggests that they may have inhaled TB contaminated air while providing care. In order to reduce the risk of transmission of infections in health care settings, the World Health Organization (WHO) recommends the use of standard precautions (WHO, 2007). Standard precautions include practicing hand hygiene: washing of hands after all contacts with patients; using personal protective equipment, such as gloves, masks, aprons and boots; practicing respiratory hygiene and cough etiquette; ensuring proper waste disposal and the maintenance of a clean and safe environment (WHO, 2007). The implementation of infection control measures has been shown to reduce nosocomial transmission of infections in clinical settings (Joshi, Reingold, Menzies, & Pai, 2006). However, we know very little about whether and how infection control is carried out in home-based care, since research on infection control in home-based care for people living with HIV/AIDS/TB is virtually non-existent. Given the high prevalence and co-infection rates of HIV and TB, research on infection control in home based care could help inform policy on home-based care and TB control. Therefore, in this study, the first to our knowledge, we explore the practice of infection control in home-based care for people living with HIV/AIDS/TB in South Africa with a specific focus on the control of HIV and TB infections. Methods Study setting and context The study was conducted in one rural and nine semi-rural (townships) communities on the outskirts of Durban in the KwaZulu-Natal province of South Africa. These communities have care organisations providing home-based care to people living with HIV/AIDS/TB. KwaZulu-Natal has the highest HIV/AIDS prevalence of 39.5% and one of the highest rates of TB in the country (Gandhi et al., 2006; UNAIDS, 2012; WHO, 2012). There are a number of home-based care organisations working across the province with varying degrees of financial and material resources and training for their volunteers. Participants Participants comprised (1) home-based care (HBC) coordinators/project managers and (2) volunteer caregivers. One HBC co-ordinator/project manager each from 10 home-based care organisations was recruited to participate in the study. The organisations were selected purposively from a list of organisations to reflect the range of organisations working in different communities in the greater Durban area. The organisations also had
384
O. Akintola and L. Hangulu
Downloaded by [Duke University Libraries] at 21:11 03 January 2015
to consent to participate in the study. Incidentally, all the organisations were funded by the Department of Health and all provided basic nursing care to patients. We purposively selected volunteer caregivers providing care to patients. Each of the organisations convened meetings with all their volunteers to inform them about the study. Those who consented to participate in the study were recruited to participate in focus group discussions. Participants were recruited if they: were volunteer caregivers working with any of the care organisations; provided home care to someone with clinical AIDS; provided care for a minimum period of six months; and were willing to respond to questions about infection control practices in home-based care. A total of 80 volunteers participated in the study. Table 1 shows home-based care coordinators/project managers’ sociodemographic characteristics, while Table 2 shows volunteer caregivers’ sociodemographic characteristics.
Procedure We conducted a qualitative study among HBC coordinators/project managers and volunteer caregivers between July 2010 and September 2011. Ten HBC coordinators/ project managers (one per organisation) participated in in-depth interviews, which were held in their offices. The interviews were conducted using topic guides drawn in English. The topic guides contained topics such as sociodemographic information, training on infection control, the practice of infection control and the barriers to the practice of infection control. Most of the interviews were conducted in English by one of the authors, while a trained research assistant conducted interviews for those who preferred to be interviewed in IsiZulu, the native language of participants. The interviews were taperecorded and lasted between 40 and 50 minutes. One focus group was conducted in each of the 10 care organisations and each focus group consisted of 4 to 11 volunteer caregivers. Table 3 provides the number of volunteers who participated in focus group discussions from each care organisation. The focus groups were conducted in convenient private rooms provided by each of the care organisations. A focus group guide containing open-ended questions was drawn in English and translated to IsiZulu. The IsiZulu version was used to conduct focus groups with the participants. The focus groups were facilitated by a trained IsiZulu-speaking Table 1. Sociodemographic characteristics of home-based care coordinators/project managers. Item Gender Male Female Age (years) 44–49 50–55 56–61 62–67 Work experience (years) 5–8 9–12 13–16
Frequency 0 10 5 2 2 1 5 4 1
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Table 2. Sociodemographic characteristics of volunteer caregivers.
Downloaded by [Duke University Libraries] at 21:11 03 January 2015
Item
Frequency
Gender Male Female Age (years) 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 Care work experience (years)
