Addressing the Shame Imposed by Healthcare Providers on Individuals with HIV/AIDS – Using Change Models and the SPELIT Power Matrix to Provide Cultural Sensitivity Training to Physicians and Nurses in Belize
by Tabia Richardson
According to the literature, “the United Nations Agency for International development and the World Health Organization estimated that 33.2 million people worldwide had HIV/AIDS in 2007 with an estimated 1.6 million living in Latin America” (Andrewin & Chien, 2008, p. 897) and the rates of prevalence and incidence were increasing worldwide. In Belize the contempt associated with HIV/AIDS is great because the “acquisition [of this disease] is perceived to be a result of immoral and voluntary actions, [due to] homosexual and promiscuous sex and the sharing of infected needles among injection drug users” (Andrewin et al., 2008, p.897). More specifically, the literature asserts that for these patients, their first experience with rejection comes from healthcare providers for whom diagnose and treated them (Andrewin et al., 2008).
This proposal is being submitted to the 4th Annual Conference of the International Center for Global Leadership in Placencia, Belize. This conference highlights different phenomenon for which global leaders offer their attention. HIV/AIDS has been on the radar for global health leaders because it not only affects health care providers, but a number of industries worldwide. This proposal highlights the phenomenon of contempt that is prevalent amongst healthcare leaders for whom serve HIV/AIDS patients worldwide, but more specifically in the country of Belize. It is hoped that through offering training, the issue of contempt may be addressed and eventually eradicated as it relates to individuals afflicted with HIV/AIDS no matter the vector of contraction.
Human Immunodeficiency Virus and Acquired Immunodeficiency Syndrome (HIV/AIDS) is a debilitating disease that can be deadly, and for some, comes with a stigma. This is a disease that is said to be an equal opportunity disease that affects people of every gender, age, race; and nationality. It can be contracted from mother to newborn, from man to man, man to woman; and can be contracted through the inappropriate handling of medical procedures.
In many countries around the world, this disease has reached pandemic levels. Due to its severity and sometimes the shame associated with it, when some people are diagnosed with this disease, they may feel as if they have the proverbial scarlet letter embossed on their person for all to see.
According to the literature, HIV/AIDS is a global health issue that causes those diagnosed with the disease to sometimes want to hide from the diagnose rather than acknowledge and confront it (Andrewin et al., 2008). In fact, “in Central America, the fear of the negative consequences of disclosing one’s HIV status – a key step in building alliances amongst patients and empowering communities living with HIV – is based on concrete instances of rejection and discrimination” (Gonzalez & Colon, 2014, p. 11). Thus, HIV/AIDS is a global health issue that needs to be better addressed by healthcare organizations. Although this disease is a well-known global health issue, interestingly it is infamous for the silence it evokes.
In 1987, “HIV was first diagnosed in Belize” (Pope, 2012, p. 1161). It is thought that the disease came to Belize from abroad from people who migrated to the country (Pope, 2012). However, once HIV/AIDS became prevalent in the country, and its effects were fully understood by the healthcare professionals, for cultural and religious reasons, its existence was somewhat ignored as well as the people who contracted the disease (Pope, 2012). Therefore, the purpose of this paper is to discuss ways to erase the disdain associated with an HIV/AIDS diagnose for Belizeans by training healthcare professionals to treat these patients with compassion rather than contempt as they fight this disease.
In the article written by Andrewin et al (2008), entitled “Stigmatization of patients with HIV/AIDS among doctors and nurses in Belize”, the authors performed an observational study in 2007 of 230 healthcare providers who diagnosed and treated HIV/AIDS patients. The researchers found that the “stigmatization imposed on patients was greatest [due to] ‘attitudes of blame/judgment’ [that were] inflicted on those with the disease” (Andrewin et al., 2008, p. 900) by doctors and nurses. They also learned that, due to the healthcare professionals’ negative feelings toward the HIV/AIDS patients, the physicians and nurses who treated them were involved in such unethical practices as “sharing a patients HIV status with colleagues without the patients’ permission, testing patients for HIV/AIDS without the patients’ consent, treating patients with HIV/AIDS with disdain compared to other patients; and they found that female nurse healthcare professionals, who spend the most time with these patients, showed more differential treatment than their male physician counterparts” (Andrewin et al., 2008, p. 902). The researchers concluded that there was a need for healthcare professionals to receive training on how to better serve patients with HIV/AIDS and that future research should investigate this phenomenon.
In the article “Therapeutic imaginaries in the Caribbean: competing approaches to HIV/AIDs policy in Cuba and Belize” (2012), the author highlights the historical differences found in the care of HIV/AIDS patients in Cuba versus those in Belize (Pope, 2012). The researcher showed how initially Cuba stigmatized HIV/AIDS; however, overtime, its healthcare system decided to provide “education about sexually transmitted infections, access to primary care, and culturally appropriate disease control” (Pope, 2012) in order to reduce the incidence and prevalence of the disease. Pope stated that unlike Belize, and its handling of this disease, the Cuban constitution mandates that medical care be granted to all; thereby permitting that all “persons living with HIV are guaranteed adequate medical care” (Pope, 2012, p. 1159) and because of this mandate, Cuba “has reduced the stigma associated with HIV and therefore has reduced negative stereotypes associated with this disease” (Pope, 2012, p. 1160). Conversely, the article showed that unlike Cuba, Belize struggles with the stigma associated with this disease. According to Pope (2012), in Belize, HIV/AIDS is seen as a “moral disease that is a result of immoral acts and thus there is no education offered” (Pope, 2012, p. 1161) concerning prevention or maintenance of this disease.
A proposed way to address the matter of compassionate HIV/AIDS healthcare delivery in the Belizean healthcare system is through the SPELIT Power Matrix (Schmieder-Ramirez & Mallette, 2007). The premise of The SPELIT Power Matrix (Schmieder-Ramirez et al., 2007) is that it assists in analyzing the environment in which an organization exists before implementing change. The acronym SPELIT stands for S: Social Environment, P: Political Environment, E: Economic Environment, L: Legal Environment, I: Intercultural Environment; and T: Technological Environment. To assess the Belizean healthcare system with the proposed organizational change, evaluating the following tenets of the SPELIT is imperative:
S: Social Environment – Belize gained independence in 1981 from the United Kingdom. The population of Belize is 377, 968 people (“United Nations”, 2016). According to the United Nations Agency for International Development, there are “3,600 adults who are 15 years old or older reported to be living with HIV/AIDS: 1,700 women and 1,800 men” (“United Nations”, 2016). In Belize’s 2015 Ministry of Health report, it is documented that of those Belizeans diagnosed with HIV/AIDS, “30.8% of them have experienced discriminatory attitudes because of their disease” (“Ministry of Health”, 2015).
P: Political Environment – Belize has two major political parties: People’s United Party and the United Democratic Party. The country also is a member of such global organizations as the United Nations, the Association of Caribbean States, and the Organization of American States.
E: Economic Environment – Belize has an agricultural economy where the main crops are sugar and bananas. The countries it trades with most frequently include: United States, Mexico, Europe; and other Central American countries – all of whom have experienced the effects of HIV/AIDS (“United Nations”, 2016).
L: Legal Environment – Belize has its own Constitution and functions under the Common Law of England. It has three different branches of its judicial system: Magistrate Courts, Supreme Court, and a Court of Appeals. As of 2003, it also is a member of the Caribbean Court of Justice with other Caribbean Nations (“World Encyclopedia”, 2016). While the treatment of HIV/AIDS patients is a human rights issue, unlike Cuba, the Belizean Constitution does not include language on the expectations of treatment for these individuals (Pope, 2012).
I: Intercultural Environment – There are a number of cultural groups living in the country including Mestizos, Creoles, Mayans, Garinagus, Mennonites, East Indians and Chinese. The country’s main language is English, but Belizean Creole, Spanish, German, and other indigenous languages are spoken.
T: Technological Environment – In 2008, Belize instituted an electronic medical record system to keep track of diagnosed HIV/AIDS patients (“Ministry of Health”, 2016). The Ministry of Health introduced this system in order to “improve capacity to monitor patients and facilitate care of people with and getting tested for” (“Ministry of Health”, 2016) having this disease. Similarly, in 2010, the Ministry of Health implemented a computer-based system called the “2010 Care-Based Surveillance System” whose purpose was to gather and store demographic information on all known Belizeans who had been diagnosed with HIV/AIDS (“Ministry of Health”, 2016).
After evaluating the areas of the SPELIT (Schmieder-Ramirez et al., 2007) and the literature, perhaps Belize could benefit from an organizational change in how healthcare organizations there address the needs of HIV/AIDS patients.
According to Andrewin and Chien (2008), “HIV/AIDS stigma discrimination compound the challenge of getting the pandemic under control” (Andrewin et al., 2008, p. 897). Surprisingly, “the healthcare setting has been identified as one of the major settings in which stigmatization urgently needs to be addressed” (Andrewin et al., 2008, p. 898) and the authors acknowledged that “little is known or documented about the attitudes and practices of healthcare workers in Belize regarding the treatment of HIV/AIDS patients” (Andrewin et al., 2008, p. 898). Therefore, because of the latter, this proposal suggests that Belize implements a community-based, health promotion intervention that can be conducted with healthcare professionals. The objective of this program would be to train physicians and nurses on how to offer competent and individualized care that would show compassion and understanding to patients who are diagnosed with HIV/AIDS — regardless of how they may have contracted the disease. This training program could also afford health care professionals a “safe place” to express and work through their biases regarding HIV/AIDS patients amongst their peers. The hope would be that, in such an environment, they would be able to acquire the tools to help to eliminate their biases. By learning new ways to render compassionate healthcare to these patients, the healthcare providers may become the non-judgmental entities these patients need to encourage and empower them to became self-efficacious as they manage their diagnosis.
When initiating organizational change in a healthcare system such as Belize, it is important to substantiate the changes by referencing theoretical change models. One change model that could be implemented to help destigmatize HIV/AIDS in Belizean medical facilities is Kurt Lewin’s Action Research Model. This model has four components to effect change: 1. Field Theory, 2. Group Dynamics, 3. Action Research; and 4. the 3-Step Model of Change (Burnes, 2004). Therefore, in keeping with Lewin’s change model, the concept of Field Theory depicts the “field” as the environment where the organizational change occurs. Thus, the field would be the Belizean medical facilities (Burnes, 2004). In endeavoring to change the perceptions physicians and nurses have toward HIV/AIDS patients, it would be necessary to also use Lewin’s Theory of Group Dynamics which states that “understanding the internal dynamics of a group is not sufficient by itself to bring about change, but that there is also the need to provide a process whereby the members could be engaged in and committed to changing their behaviour.” (Burnes, 2004, p. 983). Thus, it would be imperative that the feelings and perceptions of the Belizean physicians and nurses be regularly assessed so that the proposed organizational changes could properly take root in medical settings (Burnes, 2004). Also, to further assess the organization, an important aspect would be to determine to what extinct patients as well as healthcare professionals felt that the organizational change would benefit the organization. The latter is an example of Lewin’s principle of Action Research which “recognizes that successful action is based on analyzing the situation correctly, identifying all the possible alternative solutions and choosing the one most appropriate to the situation at hand” (Burnes, 2004, p. 983) by assessing the “felt-need” (Burnes, 2004, p. 983) of those involved is addressed. Thus, the “felt-need is an individual’s or group’s inner realization that change is necessary” (Burnes, 2004, pp. 983-984). To summarize the literature states that “unfreezing or getting rid of the former organizational norms before wholeheartedly implementing the changes in an effort for the medical professionals to “unlearn” their old organizational behaviors” (Burnes, 2004, p. 985) is imperative and thus the main goal of change management. The literature also states that when implementing the second step of organizational change called “moving” (Burnes, 2004, p. 985), it is necessary to try not to “predict or identify a specific outcome from Planned change” (Burnes, 2004, p. 985), but instead to allow organizations to be open to whatever the results that are initiated by the change (Burnes, 2004, p. 985). Finally, the last of the three steps is “refreezing” (Burnes, 2004, p. 985), which would help the health professionals to maintain the organizational changes they make overtime (Burnes, 2004).
Another change model that could be used to help the Belize healthcare system deal with the proposed organizational changes is Woodard’s Leading and Coping with Change Model (Woodard & Hendry, 2004). According to the literature, Woodard and Hendry cautions that “when change processes require fundamental shifts in the way organizational members think and act, the consequences of change can test to the utmost the organization’s capabilities and resources” (Woodard et al., 2004, p. 156). Woodard and Hendry affirm that when implementing this theory, it is imperative to offer “support for employees to learn new competencies, through formal coaching, helps them to develop the skills to manage the new situations they are faced with” (Woodard et al., 2004, p. 168) because as the change unfolds, employees continue to evaluate what is going on, and apply various coping strategies thus the premise behind this paper.
HIV/AIDS is a serious global health phenomenon. It has a particularly harmful impact in countries where the disease is attached to negative societal perceptions – especially when these perceptions negatively impact the patients which is the case in Belize (Andrewin et al, 2008). Thus, in order to gain a true understanding of this phenomenon, it is imperative to research it further. The need to ascertain the true biases that some healthcare providers have toward this patient population are interesting as this is a profession that takes an oath to help all people and to do no harm while doing so. Therefore, to learn that there are some healthcare providers who contribute to the contempt that some in Belizean society may hold towards those diagnosed with HIV/AIDS is unfortunate. The objective of this proposal is to use the SPELIT Power Matrix (Schmieder-Ramirez et al., 2007) to help to identify ways that the healthcare system in Belize might implement organizational change by instituting training for its healthcare providers, as outlined in this proposal, in order to inject more compassion into the business of treating HIV/AIDS patients in Belize.
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