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Print version ISSN 0103-2100
On-line version ISSN 1982-0194
Acta paul. enferm. vol.28 no.6 São Paulo Nov./Dec. 2015
Counseling about sexually transmitted diseases in primary care: perception and professional practice
To understand professionals’ perception of counseling about sexually transmitted diseases and HIV in primary care.
Qualitative study conducted among nurses and physicians in primary care. The data were collected through the focus group technique, anchored by the Consolidated Criteria for Reporting Qualitative Research (COREQ). Data analysis was performed by using the steps of social phenomenology of Alfred Schütz, which showed the categories of the study.
The professionals perform counseling in a reduced form based on the orientation for disease prevention. This practice is part of family planning and school activities. User access to sexually transmitted disease is marked by minimum demand. The priorities cases to receive care are emphasized. The professionals feel themselves unprepared and insecure in reporting test results and difficulties in counseling during home visits and maintaining confidentiality and privacy of user information.
The professionals perceive counseling as an important practice but find limitations and barriers to conducting counseling.
Key words: Counseling; Sexually transmitted diseases; Primary care nursing; Public health nursing; Nursing evaluation research
Counseling is an important public health practice in the challenging task of breaking the chain of transmission of sexually transmitted diseases (STDs), HIV, and AIDS. It is based on three basic tasks: providing information, assessing risks, and emotionally supporting the user. It must be done by trained health care professionals.(1) In Brazil and worldwide, counseling is an important strategy in the fight against STD, HIV, and AIDS because of the low cost of implementation and its potential effectiveness.(2,3) In addition to the preventive measures available (condoms, postexposure prophylaxis), counseling is a method to address these diseases.(1,4)
Counseling has particular relevance in situations of infection risk through sexual exposure; educational activities can improve health care quality and can be used at several different times in health facilities, not just at the offer for HIV testing.(5) In the 1980s, the Brazil Ministry of Health established testing and counseling centers in order to offer diagnosis and counseling based on the principles of voluntariness, confidentiality, anonymity, speed, and resolution of HIV diagnosis.(6) In the late 1990s, the Ministry of Health began decentralizing STD prevention activities for primary health care.(7) This has become an important area of prevention and care of these diseases because it is a priority component of the Brazilian government control of the HIV epidemic. While one of the priorities of primary care is the development of preventive actions for STD in the individual and collective context, few studies have examined how professionals act and perform (or not) counseling in daily service.(5,8)
Considering the importance of counseling as a moment in which the user and the professional relate, exchange ideas, and share knowledge,(9) it is necessary to know the perceptions of professionals about how this practice has been developed in order to guide planning and relevant actions, provide the professional a reflection on their practices, and provide them with a scientific base that can coherently and consistently support and direct their actions during counseling.(5) This study aimed to understand the perceptions of health care professionals about the practice of counseling on STD and HIV/AIDS in primary care.
This is a qualitative study based on the social phenomenology theory of Alfred Schütz,(10) which allows understanding of the social issues of human action. It is designed in the meanings of inter-subjective experience of social relationships and to meet social needs that have contextualized meaning and configure a social sense.
In this framework,(10) action is based on existential reasons related to past and present experienced (reasons why), and orientation for future action comprises the possibility of proper, early, and imaginative action, based on the subjective meaning of the action (reasons for). It addresses the classification of concepts that is the action of a particular social group. Other key concepts used in this study are inter-subjectivity and natural attitude.
The study was conducted in Montes Claros, southeast of Brazil, with 12 nurses and physicians that had worked for more than three months in primary care during the survey period and who agreed to participate. The inclusion of professionals who worked in basic health units geographically close by was avoided, and only one professional from each team (physician or nurse) was invited to participate in the study. This selection occurred after educating the manager about submitting future proposals for training of professionals. Initially, they invited 18 professionals (nine nurses and nine physicians) via an email that outlined the study objectives. Overall, six professionals refused to participate in the study.
Data were collected through a focus group technique, allowing interaction, in-depth discussion and debate on the basis of seven questions drawn up by the researcher on the following topics: counseling on STD and HIV/AIDS, the person seeking counseling intake, and monitoring health service users after counseling. The focus group was attended by a moderator/coordinator and two observers in order to record responses in a field diary. The debate was recorded in a room provided by the Municipal Health Department in January 2015; the debate was previously scheduled with the participants and lasted 1.5 hours. The focus group ended when the debate showed signs unveiling the phenomenon, the researchers’ concerns were answered, and the goals were achieved.
For data analysis, we used the social phenomenology steps:(10) reading and careful rereading; grouping of significant aspects present in the statements to compose the categories; and analysis of categories, trying to understand the “reasons for” and “reasons why” of the participants’ actions. Two researchers independently analyzed data from the focus group. The researchers eliminated the differences between the categories found through personal meetings and email correspondence.
To maintain rigor in the study, we used the Consolidated Criteria for Reporting Qualitative Research (COREQ) as a support tool.(11) However, after the transcripts of the debate were made, we did not return to participants for comment. The relationship between researcher and participants before the study was technical support for the development of actions related to STDs.
This study adhered to national and international standards of ethics in research involving human beings.
The profile of professionals is described in Table 1. The perception of professionals about the practice of counseling on STD and HIV/AIDS in primary care was grouped into two categories that address the “reasons why” and “reasons for” (Figure 1). The “reasons why” were grouped into the following categories:
|23 to 30 years||5(50.0)|
|31 to 40 years||5(50.0)|
|Married or stable relationship||6(50.0)|
|Single or divorced||6(50.0)|
|Practice of religion|
|No practiced religion||2(16.7)|
|Length of service in primary care|
|06 to 12 months||6(50.0)|
|13 to 24 months||1(08.3)|
|25 to 36 months||2(16.7)|
|37 to 48 months||1(8.3)|
|> 48 months||2(16.7)|
The first category included the views and practices on counseling about STD and HIV/AIDS. The first subcategory referred to the meaning of counseling for professionals and its use in practice. This was defined as a guide for the user to act correctly in relation to the reduction of risks for disease. It was observed that counseling is incorporated into family planning and work with teenagers in schools. The counseling consists of providing guidance on the use of contraceptive methods, especially condoms, vulnerability and disease prevention. The collective actions consisted of discussions of guidelines on the transmission and prevention of the main STDs for adolescents. It was reported that in schools, teenagers demonstrate doubts and seek clarification of professionals. The results indicate the perceived absence of specific educational groups on STD and HIV/AIDS in primary health care. The professionals considered the primary care setting to be appropriate for counseling, primarily because of relationship with the professional afforded by care longitudinality.
The second subcategory involved access, intake, and user STD treatment in basic health unit. Professionals reported that the demand for the service is minimal and, for some professionals, when it occurs, there is prioritization in attendance. The person seeking counseling intake is done according to scheduled appointment and spontaneous demand of the most common complaints. Users seek to talk to the professionals after the intake for collection of information about the particular situation for a consultation appointment. Treatment is conducted without calling sexual partners but rather focuses on drug therapy and condoms. Professionals who are asked to adopt such an approach are apprehensive about calling sexual partner because of issues involving conjugality.
The third subcategory depicts the approach and disclosure of post-test time. The approach is performed with user guidance on risk behaviors, vulnerability, window period and offering of HIV testing. In reporting the results of STD and HIV testing, there was fear because of the revelation’s consequences and the professionals’ unpreparedness, especially in notification of STD results to women and non-acceptance of the diagnosis by the sexual partners.
The second category concerns barriers that compromise the practice of counseling. The first subcategory involves inadequate syndromic approach by practitioners that could compromise the detection of STD during counseling. The second subcategory consisted of barriers in the incorporation of counseling into the home visit, such as negative experiences and lack of privacy to discuss the issue.
The third category includes the “reason for” and addresses the expectations of participants to improve counseling in primary care. The first subcategory includes the forward expectations for maintaining the confidentiality of user information about STDs obtained from the service. Professionals were concerned about the privacy management of users with STD due to breaks in confidentiality by community health workers. The professionals expect to use electronic medical records use in basic health units and know that community health workers are aware of sensitive information. The second subcategory considers expectations of professional training, mainly by the new information that is aggregated to address the user with STD so that they provide good-quality care.
The results of this study are limited because they were obtained from professionals from the same social group and who experience specific situations. As a result the findings cannot be generalized or used to establish cause-and-effect relationships. We must emphasize that this study offers interesting contributions to the understanding of how professionals perceive counseling. The findings may contribute to the reflection of professional work processes.
In this study, the significance of counseling professionals has been guided by the user guidance for minimizing the risk of certain disease. This meaning must go beyond guidelines so that the users are encouraged to express what they know, think and feel. The meaning attributed by professionals goes back to the concept of natural attitude, which refers to how humans experience the inter-subjective world, incorporated into the world of common sense. The natural attitude is influenced by prior knowledge and personal background of each subject.(10) Thus, professionals attribute the meaning of counseling on the basis of knowledge and experienced practice.
The categories related to the “reasons why” show that the actions performed in the daily work of counseling denote objective aspects, occur according to events of the past and present, and are permeated by numerous challenges. The way their activities are performed unveils knowledge and experiences. It is apprehended that professionals have discourse in common, constituting part of their classification.(10)
It was evident that counseling is minimized in the practice of family planning and school educational activities. Reduced counseling practice is justified by the difficulty of working the issue into primary care because of the associated preconceptions and stigma. The efficacy of counseling depends on users’ comfort and willingness to deal with potentially sensitive health care issues; these can be especially difficult given preconceptions and taboos.(12,13) Because of the difficulty of working with such issues, the inclusion of issues considered controversial in counseling can be facilitated in family planning.
In this study, counseling was performed by professionals with teenagers in schools for the purpose of clarification. The activities developed with teenagers are relevant because this age group has been the priority in campaigns and protection and prevention strategies, given their high susceptibility to STD.(14,15)
Longitudinality was considered important for users’ participation in counseling because of the relationship created with the professional. It is an attribute of primary care that allows monitoring the user over time by the same professionals.(16,17) Longitudinality permits formation of trust and bond with the user, which can be considered a facilitator in attendance of STD and HIV/AIDS counseling. Through consolidation of this attribute in professional practice, a new demand can be addressed more efficiently and in a problem-solving way.(18) Although longitudinality is deemed relevant by the professionals and the primary care setting is a scenario for developing the counseling, this practice is not yet consolidated in this scenario.
The access of users with STD to primary health care is still characterized by minimum demand, which may be related to stigma and discrimination. The existence of fear in seeking for services close to the patient’s residence or the fear of being identified and people finding out reduce the demand for the service. The search occurs mainly in cases of symptoms suggestive of STD, in which it is revealed to the professional situation in a particular way, after delivery care to others. Strategies are needed to ensure user access to STD and HIV/AIDS counseling and the timely use of services to achieve the best possible results. The strengthening of policy recommendations in primary care setting can be seen as a way to provide early identification of and immediate treatment of STD.(6,19)
The health care user’s intake in the primary care setting was characterized by the prioritization of care for treating diseases characterized by social stigma. Most people seeking the service because of an STD prefer not to talk about their sexual health with a professional because they feel uncomfortable about it. This could compromise the success of counseling. This stigma has been associated with shame directed to individuals in risk groups, reinforced above all by the fact that people with HIV/AIDS are perceived by society as responsible for causing their infection.(20) Intake provides universal access, strengthens the multidisciplinary work, provides qualified assistance, humanizes the practices, and stimulates the fight against prejudice.(21) It is important that primary care incorporates in its process technologies that represent the real practices such as embrancement and bound with the patient.
Regarding communication of STD results, especially in cases of HIV, we found that the professionals experience fear, insecurity, and unpreparedness in the face of the user’s reaction to the results. There are difficulties in dealing with subjective and intimate aspects of counseling involving sexuality and conjugality. The professionals express fears about speaking and communicating, revealing vulnerability of practice. As a result of this weakness in communication, counseling concentrates on biological parameters and test ordering; this fragments health care and distances it from the psychological and social suffering of users.(12,22)
Professionals adopt drug treatment without calling sexual partners; they avoid getting involved in issues that may compromise them before the service. Calling sexual partners is essential in order for them to seek institutional care and break the chain of transmission. In practice, the professionals experience personal difficulties and do not feel supported by their institution with regard to the convening of partnerships.(23) The conduct described was observed mainly for women with STDs who look for the service. It is possible to see the imbalance in power between the genders, with the man tending to produce more risk behaviors and difficulties in negotiating condom use.(24) A study among women who underwent counseling without the support of male partners pointed out that these women cannot disclose their status to a partner for fear of accusations of infidelity, violence, abandonment and loss of economic support.(25)
Detection of STD and HIV is compromised due by the syndromic approach, which is inadequate, represents a barrier, and suggests the need for training. The training of professionals in the primary care setting for counseling practice is indispensable in adapting care for a more effective response, particularly in relation to HIV.(12,22)
Another barrier is the reluctance of professionals to approach counseling in the context of home visits because of the confidentiality of conversation, privacy, and sharing the results on site. It appears that there is a lack of strategies to ensure the opportunity for counseling outside the primary care setting, representing potential loss of timely treatment. A study in Kenya with home visits to pregnant women living with HIV found high acceptance of the couples, most likely due to the result of an examination approach that ensured confidentiality and sharing of results between partners, allowing for more frequent and comprehensive monitoring.(25)
The “reasons for” reveal expectations for improving the work process in counseling to the user. Professionals have expectations regarding the use of electronic medical records, which are seen as an alternative to the breakdown of confidential information because their use is restricted by professionals. Concern about privacy stems from the fact that community health workers reside in the community where users live.(9) In the city where this study took place, documents are organized in files accessible to all professionals. In addition, professionals expect that community health workers be involved with and aware of confidentiality.
The professionals expressed desire to improve their vocational training, particularly regarding diagnosis and treatment of STD. In the primary care setting, the training of practitioners is relevant in order to improve the detection of these diseases and the approach made to the user. A study carried out in Spain with practitioners revealed the need for training in rapid testing for HIV and counseling for these professionals.(26)
Professionals’ expectations translate into improving their formation and work processes for the provision of counseling guided on ethics and integrity. These aspirations are the characteristics of this group in relation to their desires. The need felt by these professionals is shared by and is included in inter-subjectivity, in which experiences are interpreted in a reciprocal manner.(10)
It should be noted that in the social phenomenology theory of Alfred Schütz,(10) all people who share a social reality feel personal and social needs in belonging to a social group. From this perspective, individuals need to have a definition of the role they play in daily practice, determining their place in society and in a certain position, which is part of their expectations.
Professional counseling is reduced to user guidance for minimizing the risk of certain disease but is still considered a relevant practice. The achievement in primary health care involves limitations and barriers and is not consolidated. It is imperative that strategies be used to support the user approach to STD in the basic health unit at the time of home visits to establish a bond and trust in the initial contact and follow-up of cases. Professionals must be equipped not only for counseling but also for addressing issues involved in the detection and treatment of STD and HIV/AIDS. Finally, confidentiality and user information privacy must be discussed and awareness raised among professionals, especially community health workers.
To Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (in English - Coordination of Higher Education Personnel - CAPES; doctorate scholarship for Barbosa TLA).
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Received: May 14, 2015; Accepted: October 6, 2015