THE IMPACT OF AN HIV/AIDS WORKPLACE WELLNESS PROGRAMME IN A LARGE PACKAGING FACTORY Michelle Nedine Schorn Janse van Rensburg A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, in partial fulfillment of the requirements for the degree of Master of Public Health Johannesburg, 2007 ii DECLARATION I, Michelle Nedine Schorn Janse van Rensburg declare that this research report is my own work. It is being submitted for the degree of Master of Public Health at the University of the Witwatersrand, Johannesburg. It has not been submitted before for any degree or examination at this or any other University. Signed: 9th day of November 2007 iii DEDICATION for those who have died of AIDS and shouldn?t have yet iv ABSTRACT Introduction: As the impact of HIV/AIDS on the business sector has become more visible, businesses have increasingly seen the advantages of creating HIV/AIDS management programmes for their workplaces ? and some even beyond the workplace, to their surrounding communities. The aim of the study was to determine the effect and benefit of a large company?s HIV/AIDS workplace wellness programme. Study objectives were to a) describe the effect of the wellness programme as measured by differences in CD4 counts and percentages, weight, episodes of diarrhoea and sick leave; and b) to explore the perceptions and views of the occupational health nursing practitioners (OHNPs) regarding what they observe the benefit of the wellness programme to be on the general sense of health and well-being of the HIV-positive employees. Materials and methods: The study was performed at 10 of the Gauteng factories of a large multi-national packaging company. Quantitative data was collected by means of a confidential retrospective review of 36 HIV-positive employees? occupational health records. Mostly descriptive and some inferential data analysis was performed. Qualitative measurement was done through semi-structured interviews with nine OHNPs to gain information about their perceptions and opinions regarding the benefit of the wellness programme. Thematic analysis of qualitative data was carried out. Results: The benefit of the HIV workplace wellness programme was not seen when considering CD4 counts and CD4 percentages. Episodes of diarrhoea over time and absenteeism data also did not show any benefit. However, changes in weight were observed (participants gained an average of 1.5kg over the study period) although this was not statistically significant. The qualitative data showed that employees benefit from the wellness programme, particularly in terms of their physical and mental well-being. Emerging themes related to fear of loosing one?s job and denial of the reality of HIV/AIDS; stigma and discrimination in the workplace and in the community at large; trust versus mistrust of the Company?s HIV management system; acceptance of the condition; the acceptability of nutritional supplements; and the general benefit of the wellness programme. Other related themes that emerged included issues regarding VCT, peer education, the provision of anti-retroviral therapy (ART), the role of trade unions, barriers in the public health care system and OHNPs? frustrations with the wellness programme. Discussion: The most beneficial aspect of the wellness programme appeared to be the trust relationship that employees on the wellness programme have with the OHNPs. Because of this, employees experience a sense of support and are more likely to accept their HIV-positive condition. This contributes to a sense of mental well-being. Early intervention and better v management of the condition also occur and there is better compliance to treatment and disease management protocols. There was also a general sentiment that there were benefits in the use of nutritional supplements. Employees reported feeling healthier (e.g. having more energy when using nutritional supplements) and this contributed to a sense of physical well-being. A big challenge is to overcome mistrust amongst the general employee population who have not joined the wellness programme and to deal with the ever-present issues relating to the fear of loosing their job if found to be HIV-positive as well as denial of the condition. This fear and denial perpetuates the reality of discrimination and stigmatisation, which inevitably negatively affects the social well-being of HIV-positive employees. Limitations of the study included a small sample size; inconsistent data collection methods by the OHNPs in the various clinics; the complicated nature of nutritional supplementation, which makes it difficult to study superficially; and that HIV-positive employees could not be interviewed directly as they were not willing to be interviewed. Recommendations: Further research should be performed in the area of workplace wellness programmes. More efficient data collection systems should be put in place to measure the impact of HIV/AIDS and the effectiveness of workplace interventions. HIV-positive employees who have disclosed their status could be used as positive role models in HIV/AIDS programmes. Confidentiality protocols should continue to be strictly adhered to as this promotes the trust relationship. An HIV/AIDS nutritional expert should be involved in advising about the use of optimal supplements in the wellness programmes as OHNPs have differing opinions. Other health professionals could be involved in HIV wellness programmes, e.g. occupational therapists, social workers, etc. Companies should investigate how they can get involved in HIV/AIDS-related activities and partnerships in the communities where their employees live as many employees struggle with issues of poverty over-and-above being HIV-positive. vi ACKNOWLEDGMENTS Thank you to my wonderful husband, Anton. Thank you to my good friend, Stella Viljoen. Thank you to my supervisor, Dr Ronel Kellerman. Many thanks also to Dr Annemarie Bergh, Ms Daleen Casteljein, Dr Piet Becker of the MRC, Dr Salome Meyer, Ms Nicola Christofides, Sr Mariana Otto, all the sisters at the packaging company, and Ms Cherie Cawood from Epicentre. Thank you to God. vii TABLE OF CONTENTS Page DECLARATION ii DEDICATION iii ABSTRACT iv ACKNOWLEDGEMENTS vi TABLE OF CONTENTS vii LIST OF FIGURES AND TABLES xi NOMENCLATURE xii CHAPTER 1: INTRODUCTION AND LITERATURE REVIEW 1 1.1. The Corporate sector and HIV/AIDS 2 1.2. Wellness programmes 5 1.3. The concepts of health and well-being 6 1.4. Nutrition and HIV/AIDS 8 1.5. Description of the Company?s workplace programme 10 1.5.1. Research question 12 1.5.2. Study objectives 13 1.5.3. Justification of the study 13 CHAPTER 2: MATERIALS AND METHODS 14 2.1. Study method and design 14 2.2. Study population and sample 15 viii 2.2.1. Occupational health nurses 16 2.2.2. HIV-positive employees 16 2.3. Measurement 18 2.3.1. Quantitative measurement 18 2.3.2. Qualitative measurement 20 2.4. Analysis 20 2.4.1. Quantitative analysis 20 2.4.2. Qualitative analysis 21 2.5. Ethical considerations 23 CHAPTER 3: QUANTITATIVE RESULTS 25 3.1. Quantitative analysis 25 3.1.1. Background characteristics 25 3.1.1.1. Average time of participation in the wellness programme 25 3.1.1.2. Sex 26 3.1.1.3. Age 27 3.1.1.4. Medical Aid schemes 27 3.1.1.5. Supplement products 27 3.1.2. CD4 counts and percentages 28 3.1.3. Weight changes 29 3.1.4. Episodes of diarrhoea 29 3.1.5. Absenteeism 30 ix CHAPTER 4: QUALITATIVE RESULTS 31 4.1. Qualitative Analysis 31 4.2. Discussion of emerging themes 31 4.2.1. The wellness programme and HIV-positive employees 31 4.2.1.1. Theme 1: Fear and denial 32 4.2.1.2. Theme 2: Stigma and discrimination 33 4.2.1.3. Theme 3: Trust and acceptance 35 4.2.1.4. Theme 4: Acceptability of nutritional supplements 37 4.2.1.5. Theme 5: Benefits of the wellness programme 40 4.2.2. The comprehensive workplace HIV/AIDS intervention approach 41 4.2.2.1. Theme 6: Issues regarding VCT 41 4.2.2.2. Theme 7: Peer Education ? is it working? 44 4.2.2.3. Theme 8: Anti-retroviral Therapy (ART) 45 4.2.3. Other related issues regarding the wellness programme 46 4.2.3.1. Theme 9: Barriers in the public health care system 46 4.2.3.2. Theme 10: The role of trade unions 47 4.2.3.3. Theme 11: OHNP frustrations with the wellness programme 48 x CHAPTER 5: DISCUSSION 51 5.1. Limitations of the study 51 5.2. Discussion of the major findings of the study 52 5.2.1. Understanding and assessment of the impact of HIV/AIDS on the workplace 53 5.2.2. Some long and short term measures to deal with the impact of HIV/AIDS 54 5.2.2.1. Prevention programme 55 5.2.2.2. Wellness programme 55 5.2.2.3. Other management strategies 61 CHAPTER 6: CONCLUSIONS AND RECOMMENDATIONS 63 REFERENCES 67 APPENDICES APPENDIX A: Semi-structured interview guideline with occupational health nursing practitioners APPENDIX B: Ethics form and explanation of change in methodology and title of study xi LIST OF FIGURES Page Figure 1.1.: Wilcock?s definitions of well-being 7 LIST OF TABLES Page Table 2.1: OHNP sample information 16 Table 2.2: HIV-positive employee sample information 18 Table 2.3: Word associations relating to well-being 22 Table 3.1: Summary of descriptive data 26 Table 3.2: Breakdown of the types of supplement products taken 28 Table 3.3: Comparisons of CD4 counts and percentages before and after intervention 28 Table 3.4: Comparisons of weight before and after intervention 29 Table 3.5: Symmetry results for changes in episodes of diarrhoea 30 Table 4.1: VCT uptake and HIV prevalence in the factories studied 42 xii NOMENCLATURE - AIDS: Acquired Immune Deficiency Virus - AfA: Aid for AIDS - ART: Anti-retroviral therapy - ARV: Anti-retroviral - EAP: Employee Assistance Programme - GP: General Practitioner - HIV: Human Immuno-deficiency Virus - NGO: Non-government Organisation - OHNP: Occupational Health Nursing Practitioner - PLWHA: People living with HIV/AIDS - SA: South Africa - STI: Sexually Transmitted Infection - UNAIDS: Joint United Nations Programme on HIV/AIDS - VCT: Voluntary Counselling and Testing - WHO: World Health Organization - Wits: University of the Witwatersrand