Provider Fatalism Reduces the Likelihood of HIV-Prevention
Provider Fatalism Reduces the Likelihood of HIV-Prevention
We examined the relationship between provider fatalism, a belief that behavior change among HIV-infected patients is unlikely, and HIV-prevention counseling in 16 publicly funded clinics. HIV-seropositive patients (N = 618) completed surveys assessing prevention counseling in the past 6 months. Additionally, 144 interviews were conducted with providers, administrators, and patients to examine beliefs about prevention counseling. We summed the number of fatalistic comments made by providers and administrators in each clinic, and assigned these counts as clinic-level fatalism scores to survey participants. Patients in high fatalism clinics were less likely to report prevention counseling than patients in low fatalism clinics. This difference remained significant even after controlling for clinic characteristics or patients' sexual risk and health status. However, clients in high fatalism clinics were more likely to be White, gay, educated, and older. Provider fatalism is a barrier that must be addressed when implementing HIV-prevention counseling in primary care settings.
The success of antiretroviral drug therapies has prompted calls for expanding and adapting HIV-prevention services (Global HIV Prevention Working Group, 2004; Institute of Medicine, 2001). HIV-positive individuals are living longer and more sexually active lives (CDC, 2003c; Erbelding et al., 2000), and now face the challenge of maintaining safer sex practices over many years.
In the US, incorporating HIV-infected individuals into prevention activities was initially identified by the government as a key objective when a goal was established to reduce the number of new infections annually by 2005 (CDC, 2001). Unfortunately, recent studies have documented setbacks in prevention efforts, with reports of increased risk behaviors (CDC, 1999; Chen et al., 2002, 2003; Dodds et al., 2000; Ekstrand et al., 1999; Elford et al., 2002; Katz et al., 2002; van de Ven et al., 2000), sexually transmitted infections (STI) (CDC, 1999; Chen et al., 2002; Dupin et al., 2001; Klausner et al., 2000; Stolte et al., 2001), and HIV (CDC, 2003b; Katz et al., 2002), particularly among men who have sex with men (MSM). In response, the CDC (2003a, d) announced a new initiative to focus attention specifically on reducing HIV transmission by intervening with infected individuals.
A central component of this new initiative is the incorporation of prevention counseling into clinical care settings that serve patients with HIV (CDC, 2003a,d). Such counseling is currently not a standard care practice. In a recent study, 29% of patients said they had never discussed HIV prevention with their providers (Marks et al., 2002). Furthermore, the likelihood of this outcome varied by a person's race and ethnicity, with African Americans and Hispanics reporting more counseling than Whites (Marks et al., 2002). In order to be effective, risk assessments and prevention counseling need to become a routine component of ongoing primary care (CDC, 2003d).
At the request of the Health Resources and Services Administration (HRSA), we conducted a study to examine the nature and likelihood of HIV-prevention counseling in clinics publicly funded by the Ryan White CARE Act. We used a research design consisting of two methods: (1) a quantitative survey administered to patients leaving primary care appointments, which allowed us to assess the likelihood of HIV-prevention counseling, and (2) qualitative interviews conducted with service providers and patients, which allowed us to explore the perceptions of HIV-prevention counseling and barriers to its implementation. We previously reported results from this study that indicated that prevention counseling is not routine in most clinics, especially those that lack formal procedures to guide its administration (Morin et al., 2004; Myers et al., 2004). Furthermore, findings suggested that insufficiencies in appointment lengths, provider training, and funding pose barriers to the provision of prevention programming to people living with HIV (Morin et al., 2004).
In this paper, we report on findings involving provider fatalism, a belief that behavior change among HIV-infected patients is unlikely. Qualitative interviews allowed us to examine, in an open-ended manner, the types of provider beliefs and attitudes that affect the provision of prevention counseling. Fatalism emerged as one particularly salient finding in our analyses of these interviews. Here, we describe a set of procedures that we used to examine whether the providers' fatalistic beliefs are associated with the provision of prevention counseling.
The importance of exploring the effects of fatalism is highlighted by previous research. Over 50% of the healthcare providers surveyed in a recent study described their HIV-infected patients' futures as uncertain or hopeless, despite recommending the conveyance of hope as a counseling strategy (Westburg and Guindon, 2004). Research suggests that these beliefs can impact clinical services. Studies from the psychological literature have shown that providers' and patients' expectations about the likelihood of success are associated with actual outcomes in experimental or therapeutic interventions (Martin et al., 1977a,b; Stewart-Williams and Podd, 2004). Additionally, multiple studies in the HIV-prevention literature have documented a relationship between an individual's fatalistic attitudes and his or her HIV-risk behaviors (Kalichman et al., 1997; Somlai et al., 2000). In light of these findings, we expected that fatalistic beliefs among providers, as identified in our qualitative interviews, would be associated with less frequent administration of HIV-prevention counseling.
Abstract and Introduction
Abstract
We examined the relationship between provider fatalism, a belief that behavior change among HIV-infected patients is unlikely, and HIV-prevention counseling in 16 publicly funded clinics. HIV-seropositive patients (N = 618) completed surveys assessing prevention counseling in the past 6 months. Additionally, 144 interviews were conducted with providers, administrators, and patients to examine beliefs about prevention counseling. We summed the number of fatalistic comments made by providers and administrators in each clinic, and assigned these counts as clinic-level fatalism scores to survey participants. Patients in high fatalism clinics were less likely to report prevention counseling than patients in low fatalism clinics. This difference remained significant even after controlling for clinic characteristics or patients' sexual risk and health status. However, clients in high fatalism clinics were more likely to be White, gay, educated, and older. Provider fatalism is a barrier that must be addressed when implementing HIV-prevention counseling in primary care settings.
Introduction
The success of antiretroviral drug therapies has prompted calls for expanding and adapting HIV-prevention services (Global HIV Prevention Working Group, 2004; Institute of Medicine, 2001). HIV-positive individuals are living longer and more sexually active lives (CDC, 2003c; Erbelding et al., 2000), and now face the challenge of maintaining safer sex practices over many years.
In the US, incorporating HIV-infected individuals into prevention activities was initially identified by the government as a key objective when a goal was established to reduce the number of new infections annually by 2005 (CDC, 2001). Unfortunately, recent studies have documented setbacks in prevention efforts, with reports of increased risk behaviors (CDC, 1999; Chen et al., 2002, 2003; Dodds et al., 2000; Ekstrand et al., 1999; Elford et al., 2002; Katz et al., 2002; van de Ven et al., 2000), sexually transmitted infections (STI) (CDC, 1999; Chen et al., 2002; Dupin et al., 2001; Klausner et al., 2000; Stolte et al., 2001), and HIV (CDC, 2003b; Katz et al., 2002), particularly among men who have sex with men (MSM). In response, the CDC (2003a, d) announced a new initiative to focus attention specifically on reducing HIV transmission by intervening with infected individuals.
A central component of this new initiative is the incorporation of prevention counseling into clinical care settings that serve patients with HIV (CDC, 2003a,d). Such counseling is currently not a standard care practice. In a recent study, 29% of patients said they had never discussed HIV prevention with their providers (Marks et al., 2002). Furthermore, the likelihood of this outcome varied by a person's race and ethnicity, with African Americans and Hispanics reporting more counseling than Whites (Marks et al., 2002). In order to be effective, risk assessments and prevention counseling need to become a routine component of ongoing primary care (CDC, 2003d).
At the request of the Health Resources and Services Administration (HRSA), we conducted a study to examine the nature and likelihood of HIV-prevention counseling in clinics publicly funded by the Ryan White CARE Act. We used a research design consisting of two methods: (1) a quantitative survey administered to patients leaving primary care appointments, which allowed us to assess the likelihood of HIV-prevention counseling, and (2) qualitative interviews conducted with service providers and patients, which allowed us to explore the perceptions of HIV-prevention counseling and barriers to its implementation. We previously reported results from this study that indicated that prevention counseling is not routine in most clinics, especially those that lack formal procedures to guide its administration (Morin et al., 2004; Myers et al., 2004). Furthermore, findings suggested that insufficiencies in appointment lengths, provider training, and funding pose barriers to the provision of prevention programming to people living with HIV (Morin et al., 2004).
In this paper, we report on findings involving provider fatalism, a belief that behavior change among HIV-infected patients is unlikely. Qualitative interviews allowed us to examine, in an open-ended manner, the types of provider beliefs and attitudes that affect the provision of prevention counseling. Fatalism emerged as one particularly salient finding in our analyses of these interviews. Here, we describe a set of procedures that we used to examine whether the providers' fatalistic beliefs are associated with the provision of prevention counseling.
The importance of exploring the effects of fatalism is highlighted by previous research. Over 50% of the healthcare providers surveyed in a recent study described their HIV-infected patients' futures as uncertain or hopeless, despite recommending the conveyance of hope as a counseling strategy (Westburg and Guindon, 2004). Research suggests that these beliefs can impact clinical services. Studies from the psychological literature have shown that providers' and patients' expectations about the likelihood of success are associated with actual outcomes in experimental or therapeutic interventions (Martin et al., 1977a,b; Stewart-Williams and Podd, 2004). Additionally, multiple studies in the HIV-prevention literature have documented a relationship between an individual's fatalistic attitudes and his or her HIV-risk behaviors (Kalichman et al., 1997; Somlai et al., 2000). In light of these findings, we expected that fatalistic beliefs among providers, as identified in our qualitative interviews, would be associated with less frequent administration of HIV-prevention counseling.
Source...