Vietnam

Spotlight: Binh Duong Hospital

Applying QI methods to the reduction of HIV-related stigma and discrimination at Binh Duong Hospital, Vietnam

Background

Reducing stigma and discrimination (S&D) among people living with HIV (PLHIV) and key populations is critical for Viet Nam to reach the 90-90-90 targets. The Viet Nam Administration for HIV/AIDS Control (VAAC) is currently implementing a national strategy in partnership with Health Advancement in Vietnam (HAIVN) to reduce HIV-related S&D in healthcare settings.

Binh Duong Province is approximately one hour from Ho Chi Minh City, and 1,110 km south of Hanoi. Binh Duong Hospital is the largest hospital in the province, with 33 departments and over 1,000 healthcare workers (HCW). The hospital provides care to over 600 PLHIV. HIV quality improvement (QI) activities (HIVQUAL) have been implemented in the HIV clinic since 2014.

Implementation of stigma-reduction QI activities

Baseline Measurement and Planning
In late summer 2018, a baseline assessment of HIV-related S&D among HCWs and PLHIV was conducted at Binh Duong Hospital, revealing moderate to high levels of S&D. A design meeting was convened with the Hospital’s Vice Director, Head of Obstetrics and Gynecology Department (OB-GYN), Head and staff of the General Planning Department and a representative from the HIV clinic. As part of this meeting, attendees discussed results of the assessment and developed a plan for reducing HIV-related S&D throughout the hospital.

Of particular concern to attendees was the result showing that 48.6% of staff reported use of double gloves when caring for PLHIV. This indicator was chosen as the first target of S&D QI activities. OB-GYN was selected as the first department to implement these activities due to perceived feasibility (strong support from leadership of OB-GYN and staff already trained in prevention of mother-to-child transmission), ease and precision of measurement (direct observation), and minimal required funding. A fishbone diagram was developed by OB-GYN staff to analyze the root causes of double glove use, which included: lack of correct knowledge regarding standard precautions (SP), prejudice towards PLHIV, peer pressure from other colleagues in the hospital, and lack of routine monitoring and evaluation to ensure compliance with SPs (Figure 2).

Intervention
Informed by findings of root cause analysis, an intervention was implemented, comprising didactic sessions on basic knowledge of HIV, standard precautions, and post-exposure prophylaxis (PEP) and strengthened enforcement of hospital codes of conduct. The intervention was explicitly designed to be interactive, and included games, debates, and testimonials from PLHIV and a HCW treated with PEP. To ensure efficient use of resources and HCW time, the intervention was integrated into OB-GYN’s twice-weekly staff meetings. Documentation of implementation progress was recorded in an online form to inform subsequent interventions. In addition, the hospital team attended weekly online meetings with teams from HAIVN, Provincial HIV/AIDS Prevention and Control Center (PAC), and other implementing facilities to share progress, challenges, and lessons learned.

Results
After one month of intervention, measurement of S&D indicators was repeated and improvement was seen across multiple indicators (Figure 3). In particular, the proportion of HCWs reporting use of double gloves decreased by >20%. Following the success of this intervention in OB-GYN, there are now plans to scale up S&D-reduction activities in other hospital departments.

Lessons Learned

Through application of QI methods, staff at Binh Duong Hospital successfully improved knowledge of HIV transmission and decreased use of double gloves—two key drivers of S&D in the healthcare setting. In its approach, the hospital team adopted several ”best practices” that are crucial to the success of S&D QI activities:

  • Integration of S&D QI interventions into routine activities. For S&D QI interventions to be sustainable, they must be integrated into existing workflows and routinized. Incorporating S&D QI interventions into ongoing activities, such as weekly staff meetings, serves to reinforce key messaging on a routine basis at minimal cost to staff.
  • Application of root cause analysis and small-scale tests of change to drive selection of contextually meaningful QI priorities. Small-scale tests of interventions, even when applied to a single hospital department, generate knowledge that is vital to scale-up success. Although the core drivers of S&D are common across contexts, how they manifest themselves—and the degree to which they are expressed—may differ from one facility to another. Applying QI methods, such as root cause analysis, ensures that priorities for action to reduce S&D are selected in response to local context.
  • Active involvement of PLHIV in planning and implementation. Participation of PLHIV was effective in heightening HCWs’ understanding of the harmful effects of S&D and, importantly, fostered a collaborative approach to S&D-reduction activities.
  • Support of knowledge-building activities through policy change and enforcement. Translation of gains in knowledge to sustained changes in behavior requires institutional support, leadership, and mechanisms for enforcement and reinforcement. Strengthening S&D policies and HCW codes of conduct at the hospital level, and identifying champions to model best practices,are two strategies for ensuring knowledge is translated predictably into practice.

Acknowledgements

In its production of this Spotlight, UCSF-HEALTHQUAL thanks the staff of Binh Duong Hospital, HAIVN, and VAAC for their contributions and careful review. The Southeast Asia Stigma Reduction QI Learning Network is supported by the U.S. President’s Emergency Plan for AIDS Relief through CDC-Vietnam and the Health Resources and Services Administration’s (HRSA) Quality Improvement Capacity for Impact Project (QICIP). The contents are the responsibility of UCSF-HEALTHQUAL and do not necessarily reflect the views of the U.S. Government.