General Practitioners’ Beliefs about the Provision of Behavioral HIV Risk Assessment and Prevention Counseling to Patients: Theory of Planed Behavior
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Date
2007-02
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Addis Abeba Universty
Abstract
Background: The magnitude of HIV/AIDS is ever increasing in many parts of the world,
especially in Sub-Saharan Africa, despite recent improved access to antiretroviral treatment.
This calls for timely, coordinated, and intensified interventions including prevention, care,
and treatment services. Accordingly, the government of Ethiopia, particularly, Addis Ababa
health bureau has planned and been working hard to improve access to HIV prevention and
treatment services. One strategy which comes to light is to integrate VCT services in to
already available health service packages. To facilitate the integration process, it would be
crucial to identify and address those determinant factors that may affect clinicians’ provision
of HIV risk assessment and prevention advices to their patients.
Objectives: - The objectives of this study are: (1) to explore whether the General
Practitioners (GPs) ask patients about their sexual history and assess behavioral risk to HIV
and provide HIV prevention advices, (2) to describe circumstances under which the GPs ask
patients about their sexual history and assess behavioral risk to HIV and provide prevention
advices to patients, and (3) to identify behavioral, normative and control beliefs of the GPs
to ask patients about their sexual history and assess behavioral risk to HIV and provide
prevention advices to patients
Methodology: - The study employed a qualitative study design with individual in-depth
interviews. An open-ended semi-structured interview guide was developed based on the
framework of the theory of planned behavior (TPB). This guide was translated into Amharic
and used to conduct the in-depth interviews with the GPs in order to get a thorough
understanding of the feelings and thoughts of the GPs. The interview guide was used to
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elicit from the GPs the factors that may affect their provision of these two clinical services:
(1) Asking patients specific questions about their sexual history and assessing behavioral
risk to HIV, and (2) providing HIV prevention advices to their patients.
An elicitation in-depth interview was conducted with twenty eight GPs, which was the
saturation point for this study, to identify those belief factors which may affect their “Asking
of patients specific questions about their sexual history and assess behavioral risk to HIV”
and “providing advice to patients about HIV prevention”. The study was conducted from
January to February 2007 in Addis Ababa, Ethiopia.
Audio tape was used to record the responses of the twenty four GPs based on their
willingness and for the rest four interviews were dictated as these GPs were not willing on
the use of a tape recorder. All audio taped interviews were transcribed verbatim. The
dictated interviews were also expanded and organized. The content analysis was conducted
employing the thematic qualitative data analysis method to sort out all statements relevant to
the components of TPB. For each clinical action, summary analysis was made to put the
verbatim statements and the expanded notes related to the behavioral beliefs, normative
beliefs and control beliefs of the GPs into the following lists respectively: (1) positive and
negative behavioral beliefs about the outcomes or attributes of the action, (2) people or
groups that encourage or discourage the action, and (3) factors or situations that make it
easier or more difficult to perform the action.
The positive and negative behavioral beliefs about the outcomes or attributes of each clinical
action were organized into six major themes or categories. The sources of normative
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influences were grouped as approving and disapproving the behavior. The control beliefs
were organized as facilitators and barriers/constraints. Actual phrases of the GPs were used
to highlight important findings as needed.
Results: - According to the study results, most of the GPs stated that they rarely ask patients
specific questions about their sexual history and assess sexual behavioral risk to HIV and
provide advice to patients about HIV prevention because of the various beliefs they
indicated in relation to providing these services. The GPs indicated that they provide the two
clinical services only to patients they think are at risk of acquiring HIV/AIDS based on the
patients’ history and findings of physical examination. The GPs stated that they ask patients
history about sexual behaviors including history of condom use, multiple sexual partners,
and sexually transmitted diseases (STD) to assess behavioral risk to HIV. They claimed that
these services are provided to patients privately, by being friendly and respectful as much as
possible, by letting no one to enter the examination rooms.
The GPs have described various behavioral, normative and control beliefs which might have
affected their provision of these services to patients. The important behavioral beliefs of the
GPs identified were categorized into six different, but not mutually exclusive, themes which
include Patient Confidence, Patient Discomfort, Valuable Patient Care, Impact on Time and
Money, Professional Protection and Competence themes.
Pertaining to the normative beliefs, the GPs described various sources of normative
influences (referents) which either approve or disapprove the provision of HIV prevention
services to patients. These identified referents included: friends, colleagues, patients,
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popular media such as TV and Radio, organizations such as PRO-PRIDE, FHI, WHO,
JOHN HOPKINS which participate in HIV related trainings, Hospital administration and
Addis Ababa health bureau.
The GPs have also described important control beliefs which may facilitate or constrain their
provision of the two clinical services to patients. Among the important facilitating factors
identified include: presence of VCT, ART, & Care and Support services for patients,
training on Provider Initiated Counseling and Testing (PICT), having the opportunity to see
patients without family/friend present, having the opportunity to see young patients who are
open to the idea, and patients with complaints related to HIV.
Some of the important factors identified by the GPs to constrain the provision of the two
services to patients include: lack of private examination rooms, having many patients to
examine, low salary and poor incentive schemes, cultural barrier to talk about sexual
matters openly, and stigma and discrimination against HIV patients by the society.
Conclusion and Recommendation: - According to the results of this study the general
practitioners rarely provide HIV prevention services to their patients because of their various
beliefs identified about the provision of these services. These services are provided only to
those symptomatic patients presenting with HIV related problems, excluding the vast
majority of those asymptomatic patients who may benefit from early detection and
treatment. This study has tried to identify those behavioral, normative and control beliefs
which are relevant to the population under study (the general practitioners) and their
behavior (the provision of HIV prevention services to patients). The identified belief factors
must be measured quantitatively to understand which factor(s) most affected the behavior.
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Thus, in order to bring behavioral change in this area, any intervention developed should be
designed to target and change the belief factor(s) in such a way that it affects attitude,
subjective norm, and perceived behavioral control over the behavior thereby leading to a
change in intention and behavior.
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Keywords
General Practitioners’ Beliefs about the Provision of Behavioral HIV Risk