EFFECTS OF PEER GROUP INTERVENTION ON WORK-RELATED HIV PREVENTION MfO EFFECTS OF PEER GROUP INTERVENTION ON WORK-RELATED HIV PREVENTION Thank you very much. Today, I am going to share our work on the effects of peer group intervention on work-related HIV prevention for urban health workers in Malawi. FOR URBAN HEALTH WORKERS IN MALAWI

Authors Jane Chimango1 Chrissie P.N. Kaponda1 Angela Chimwaza1 Diana L.N. Jere1 James L. Norr2 Kathleen F. Norr2 1Kamuzu College of Nursing, University of Malawi 2University of Illinois at Chicago This project is a collaboration of Kamuzu College at the U. of Malawi and the University of Illinois at Chicago.

Health Workers – A Potential Resource for HIV Prevention Health workers are important for HIV prevention because people know and trust them Unsafe practices can put both health workers and clients at risk of HIV in health facilities HOSPITAL WORKER Health workers are important for HIV prevention because people know and trust them Unsafe practices can put both health workers and clients at risk of HIV in health facilities

Purpose To examine the impact of an HIV prevention peer group intervention for urban health workers at a central referral hospital in Malawi, on: Universal precautions knowledge Universal precautions reported behaviors HIV and AIDS related client teaching So the purpose of this presentation is to examine the impact of an HIV prevention peer group intervention for urban health workers at a central referral hospital in Malawi, on: Universal precautions knowledge Universal precautions reported behaviors HIV-related client teaching This study is part of a larger study using health workers as HIV prevention leaders in rural areas

A large referral hospital was the site for the study. Above you see the entrance gate, a consulting room, one of the many walkways connecting different wards and clinics, and an ambulance bringing a patient to the casualty department The hospital has over 800 employees and a full range of services, including emergency care.and AIDS testing and treatment.

Mzake ndi Mzake: The Intervention A peer group intervention - semi-structured small group meetings Facilitated by a trained volunteer from the hospital & a project nurse Emphasizes building self-efficacy: role plays and rehearsals, skill-building, group support, guided values discussions The intervention we offered to the workers was called Mzake ndi Mzaek or Friend to friend It is a peer group intervention with multiple sessions of semi-structured small group meetings The groups were facilitated by a trained volunteer from the hospital & a project nurse The sessions all emphasized building self-efficacy through active learning such as: role plays and rehearsals, skill-building, group support, guided values discussions

Mzake ndi Mzake: The Intervention 6 general sessions on HIV/AIDS, sexuality, condom use, partner negotiation and community prevention 4 sessions for health workers on AIDS treatment, universal precautions, teaching clients and ethical issues 855 clinical and non-clinical workers participated (nearly the entire workforce) There were 6 general sessions [on personal HIV/AIDS prevention , sexuality, condom use, partner negotiation and community prevention ] and 4 sessions for work-related HIV and AIDS, including AIDS treatment, universal precautions, teaching clients and ethical issues Both clinical and non-clinical workers were invited to come to sessions 855 HW participated (nearly the entire workforce)

Method We compared independent random samples of urban health workers at two different times Baseline (n= 366) Final survey, an average of 6.5 months after the intervention (n=551) No significant differences between baseline and final samples in gender, age or education About 40% male, About 58% were over age 35 Nearly half had finished secondary school. To evaluate the intervention, we compared independent random samples of urban health workers at two different times The Baseline had a sample of 366 workers, and . A final survey of 551 workers that took place an average of 6.5 months after the intervention (n=551) IF TIME PERMITS ADD We chose to use a quasi-experimental design because: No control group was possible - there was no similar hospital nearby Also, it was not feasible to randomly assign different workers or units because of frequent informal contacts There were no significant differences between the baseline and final sample in gender, age, or education. Health workers were about 40% male, About 58% were over age 35, and Nearly half had finished secondary school.

Job Categories at Baseline and Final However, job category did differ between the baseline and the final. We divided the workers into 3 broad job categories: Clinicians and technicians, who have some professional training. Clinical support workers have little training, such as ward attendents, but have some direct patient contact. Non-clinical workers had jobs ranging from administration to guards. Some of these workers may have indirect exposure, such as those in the laundry At the baseline survey, we had a higher proportion of clinical and technical workers than there were in the overall work force. We corrected this at the final survey and had about 2/5 clinical workers, 2/5 clinical support workers and 1/5 non-clinical workers. **p<.01

Universal Precautions Knowledge (% correct –20 items on hand washing, gloves, cleaning, sharps) We looked at overall knowledge about universal precautions, 20 items about correct hand washing, glove use, cleaning procedures and disposal of sharp objects. Knowledge was relatively high even at baseline. There was a small but significant increase in knowledge from the baseline survey to the final survey. We also looked at knowledge in each of the four areas and they also increased *p<.05

Regression: Predicting Universal Precautions Knowledge Because we know that the final sample included many more lower level workers, we wanted to see whether the effects of the intervention remained after controlling for type of job as well as gender and educational level. For job, we used two dummy variables, if a clinical or technical worker and if a non-clinical worker, with clinical support workers the reference category. Education was divided into two categories, identifying whether the worker completed secondary school. The adjusted R-square was .289, All of these predictors together explained about bout 29% of the variation in knowledge of universal precautions. The time of the interview (that is, before or after the intervention) remained a significant predictor. Being male and being a non-clinical worker related to less knowledge, while more education and being a clinical worker related to more knowledge

Reported Glove Wearing (Av Reported Glove Wearing (Av. Frequency for 4 situations, Range 1-5, 5 = Always) We then asked workers how often they wore gloves in 5 different situations. Reported glove wearing was nearly at the maximum at baseline and did not increase significantly. We should add that our observations showed that many workers donned one pair of gloves in the morning and did not change them, so this high rate doesn’t necessarily mean safe practice. . No Significant Difference

Multiple Regression: Predicting Reported Glove Wearing We also performed a multiple regression, but as might be expected, the variation explained was very low (under 2%). Only one factor related significantly to reported glove wearing – non-clinical workers were less likely to report glove wear. This may be partly because some non-clinical workers answered that they didn’t wear gloves for different situations instead of saying that these situations did not apply to their job.

Reported Hand Washing (Av Reported Hand Washing (Av. Frequency for 4 situations, Range 1-5, 5 = Always) We asked similar questions about how often the health worker washed hands in 4 different situations. Health workers reported significantly more hand washing after the intervention.. **p<.01

Multiple Regression: Predicting Reported Hand Washing We then performed a multiple regression with hand washing as the dependent variable. The predictors explained about 7.5% of the variation in hand washing. The time of the survey – before or after the intervention -- remained a significant predictor of hand washing when all the other factors were controlled. Unfortunately, being a clinical worker, when all the other factors were controlled, related to less reported hand washing.

Reported HIV Teaching (% done of 6 HIV and AIDS teaching activities) Finally, we asked if people had done 6 different HIV and AIDS related client teaching activities in the last month. Situations included discussion with a patient or families about: their HIV status, safer sex/condoms, stigma and how to cope, care giving protection, having an HIV test). This was scored as the % done of applicable items, answered only if applicable The proportion of health workers who reported that they had engaged in these teaching activities increased significantly after the intervention. **p<.01

Multiple Regression: Predicting Reported Client Teaching In the multiple regression, having had the intervention and demographic factors explained about 8% of the variation in reported client teaching Having had the intervention and being male related to more reported teaching, while being a non-clinical worker related to less client teaching

Urban Health Workers- Summary After the intervention: Knowledge increased significantly Reported glove wearing was very high initially and did not increase Hand washing showed a significant increase Reported HIV-related teaching was significantly higher Now I’d like to summarize these findings Universal Precautions Knowledge increased slightly but significantly Knowledge also affected by gender, education, and job Reported hand washing and glove wearing were very high Only reported hand washing showed a significant increase after the intervention [Clinicians/technicians were less likely to report hand washing than clinical support groups] Client Teaching Reported HIV-related teaching was significantly higher after the intervention [Being male also related to more reported teaching] Thus, participating in the Mzake ndi Mzake peer group intervention had positive impacts on hospital workers These changes occurred despite understaffing and lack of resources in health care facilities

Recommendation HIV prevention intervention should be available for all health workers to enhance: Prevention of HIV transmission in the health facility Client teaching about HIV and AIDS Mzake ndi Mzake or a similar intensive HIV prevention intervention should be made available for all health workers because participation can enhance: Prevention of transmission in the health facility, which protects both the health worker and the client and Increased client teaching about HIV and AIDS

Acknowledgements This project is funded by grants from the World AIDS Foundation and the National Center for Nursing Research (R01 NR08058). We would like to thank the many officials, university administrators, health workers and community members who have generously offered their time and support. Goodbye from Lake Malawi, the warm heart of Africa