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Hawaii Med J. Jun 2010; 69(6): 142–144.
PMCID: PMC3118015
Prevention of Community-Associated Methicillin-Resistant Staphylococcus aureus Infection Among Asian/Pacific Islanders: A Qualitative Assessment
Rachel M Ciccarone, MPH,corresponding author Mary Kim, MSPH, Alan D Tice, MD, Michele Nakata, MD, Paul Effler, MD, Daniel B Jernigan, MD, Denise M Cardo, MD, and Ronda L Sinkowitz-Cochran, MPH
Division of Healthcare Quality Promotion, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA (R.M.C., D.B.J., D.M.C., R.L.S.)
Hawai‘i Department of Public Health, Honolulu, HI (M.K., M.N., P.E.)
University of Hawai‘i, Honolulu, HI (A.D.T.)
corresponding authorCorresponding author.
Correspondence to: Rachel M. Ciccarone MPH, CHES Centers for Disease Control and Prevention 1600 Clifton Road, Mailstop K-40 Atlanta, GA 30333 Ph: (770) 488-6542 Fax: (770) 488-5962 Email: rciccarone/at/cdc.gov
Background
Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) has been increasingly reported over the past decade, including in Asian/Pacific Islanders (A/PIs).
Methods
We conducted ethnographic interviews in O‘ahu and Kaua‘i, Hawai‘i, with 10 Asian/Pacific Islanders identified as having a history of CA-MRSA infections.
Results
Most (7/10) thought skin infections were not a new problem in Hawai‘i. Most (8/9) attempted to self-treat the infection prior to seeking medical care with a range of home remedies and store-bought solutions. Most respondents did not initially comprehend the severity of their infection and only sought medical treatment after concern from family, unbearable pain, and/or other symptoms of illness.
Conclusion
Clinicians should be aware of the reportedly frequent use of home remedies by this population, as it may potentially contribute to interactions when treatments are combined. If clinicians and public health professionals do not address perceptions and misperceptions of how MRSA is acquired, it will be very difficult to prevent infection, and may also delay individuals from seeking treatment.
Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) has been increasingly reported over the past decade among various minority populations, including Asian/Pacific Islanders (A/PIs).13 Geographic factors and environmental aspects have been proposed as contributing to the higher rates of CA-MRSA among populations such as A/PIs.2 Furthermore, investigations of CA-MRSA outbreaks have identified certain behaviors that lead to acquisition of disease such as sharing of personal items (e.g., soap, towels), self-draining of lesions, and inadequate personal hygiene.46 No studies to date have focused on identifying specific risk factors for and measures to prevent CA-MRSA infection among A/PIs, and most studies have not provided information about behavioral risk factors for disease prevention derived from personal experience and individual perception of infection from those with disease.2
The authors conducted ethnographic interviews with A/PIs to identify perceived sources of infection and barriers and facilitators to the prevention of CA-MRSA, including cultural customs, environmental influences, and daily activities; and to understand how best to reach A/PIs with culturally appropriate prevention messages.
In September 2003, ethnographic interviews were conducted (i.e., in-depth interviews with a person of another culture in order to begin understanding his or her world view, beliefs and life situation) on the Hawaiian islands of O‘ahu and Kaua‘i with 10 A/PIs identified as having CA-MRSA infection. Potential interviewees were identified through a convenience sample of referral by local physicians and were offered a $50 gift certificate to a local drugstore for their time. Enrollment criteria required any potential interviewee to have a physician-diagnosed MRSA skin or soft tissue infection with onset in the community in the past 12 months. Pre-interview screening of all potential interviewees was conducted by a member of the research team, and potential interviewees were excluded if they had a history of factors that may be associated with healthcare-associated MRSA such as a percutaneous device, dialysis, surgery, hospitalization or residence in a long-term care facility in the past 12 months.7 Interviews were conducted at a variety of locations, including individual homes as well as central locations, based on interviewee preference. Interviews were no longer than one hour and were conducted and recorded in person by two researchers. The two researchers that conducted the interviews were not from Hawai‘i; one is a behavioral scientist, and one is a health communications specialist. Although the two researchers served in rotating roles, for each interview one interviewer was the primary spokesperson who asked the questions and interacted with the interviewee, and the other interviewer took notes to supplement the audio taping. The interview guide consisted of a set of primary questions, with additional probing questions to use if the desired information was not obtained by the primary question. For example, one of the questions was “Please describe to me how you first found out you had a skin infection”. This primary question had a series of probing questions under it such as “How did you find out you had a skin infection”, “How did you get it”, “Where on your body was it”, and “What do you think caused it”. Interview questions were on topics such as acquisition, transmission, treatment, and prevention of disease. All interviews were tape-recorded and transcribed to supplement the notes taken during the interview. Data were coded using qualitative methods to assess themes and aggregated into standardized groups/categories using qualitative methods. Questions were standardized and open-ended, therefore more than one response was sometimes given for each question. Some respondents did not answer certain questions; therefore, summary analysis of the responses to these questions may have denominators other than 10.
Respondents were predominantly male (8/10), with an age range of 20 – 60 years, and from a variety of racial/ethnic backgrounds. Most (7/10) had children, with an average of one child each, and a range of 1–12 persons per household. Half were married and half were employed; none were homeless. Respondents had an average of 12 years of education, with 3/8 respondents having a college degree. Most (7/10) thought skin infections were not a new problem in Hawai‘i; (6/8) felt it was a common problem. Many (7/10) were familiar with “staph” as a term for the bacteria Staphylococcus aureus, but only one recognized the term “MRSA.” Perceptions varied as to how people (in general) acquire skin infections versus how the respondents personally acquired the infection. Most respondents identified open sores/cuts, poor hygiene, and activities in the ocean as ways to get MRSA infection (Table 1). Other responses included allergies, stress, plants in the jungle, sweat, public items such as a toilet seat or shopping cart, genetics, and too much deodorant. Perceptions regarding how people (in general) and how they personally can prevent infection focused on practicing good personal hygiene and avoiding swimming in bodies of water such as the ocean (Table 1). Additional ways to prevent infection mentioned by respondents included avoiding plants, watching where you walk, relax/get a massage, and staying away from others with skin infection.
Table 1
Table 1
Reported Routes of Acquisition of CA-MRSA, and Ways to Prevent It, for Interviewees Themselves, as well as the General Public, with Qualitative Quotes Included
The majority (6/9) recognized that they had a skin infection when the area on their skin became swollen. Others noted pain and/or itchiness. Infection sites included the leg, back of head/neck, foot, elbow, buttock, and/or eye. No household family members or friends had a skin infection at the same time; however, 3 respondents did note infection in family members (2 in household family members, and 1 in a non-household family member) following their own infection.
Most (8/9) attempted to self-treat the infection prior to seeking medical care with a range of home remedies (5/8) including hot water and Hawai‘ian salt, lemongrass, baby oil, herbs, popping/draining the sore, warm compresses; and store-bought solutions (3/8) including gout pills, dandruff shampoo, and/or prescription medicines provided by others. The duration of time from onset of illness to clinician-provided medical treatment ranged from one day to several months with no interviewees reporting specific barriers to treatment. Most respondents did not initially comprehend the severity of their infection and only sought medical treatment after pressure/concern from family, unbearable pain, and/or other symptoms of illness (e.g., oozing blisters).
Although there were no specific barriers to treatment reported, psychosocial issues such as depression, embarrassment, and shyness were reported to have influenced time to seeking medical attention. One respondent stated, “… I'm afraid they're going to tell me I, I have something really bad, and then I'm going to, ah, man. I'd rather not know …”
The majority (8/10) of interviewees spent their weekdays or weekends participating in ocean water activities such as swimming, surfing, fishing, diving, and/or kayaking. The majority (8/10) also stated that they showered at least once daily; some persons reported sharing of towels, bedding and clothing.
Most (7/10) felt that having a skin infection affected their life; however, the perceived impact varied, often based on the site and severity of infection. The perceived impact of the infection included not being able to go into the water/ocean, having a scar/blemish, loss of sleep, pain, not being able to wear shorts anymore, and not being able to work anymore. One respondent stated, “The very worst thing is, I guess, just having it, and going to the hospital, and having all kind of needles in me, and the doctors have to come in and peel the skin off… That's, to me, that's the worst that ever happened to me.”
Reported emotional impact of infection on the respondents varied, and included feelings of fear, trauma, irritation, anger, disgust, stress, depression, and the overall feeling of being “puzzled.” Most (8/10) did not remember/did not know what their healthcare provider told them it was or what caused it. Regarding this, one respondent stated, “[The doctor] Told me it was um, ah, ---, it was some, he said it was skin disease. He said a name, but I don't remember the name of it…”
All respondents, however, remembered being informed by a physician of the diagnosis of skin infection. Most (9/10) were given antibiotics and self-reported adherence to the medications was high. Only a few reported having to cover their wounds with dressings and adherence to dressing changes varied.
When asked about the best method for receiving general information, 5/8 respondents stated a printed format such as a newspaper or brochure. Other methods included broadcast media, such as television and radio. The majority of persons did not have a computer and were not comfortable using one. The preferred method for all respondents to receive medical information was a verbal conversation with a medical provider; however, most (7/10) stated they wanted written documents such as pamphlets/brochures as “take homes.” The most trusted source of medical information, however, was friends and family (7/10), especially those employed in healthcare (4/7).
Most said that if they had to give one piece of advice to someone with CA-MRSA it would be to get treatment/go to the doctor as soon as possible. Other responses included to stay out of the water/ocean, ask more questions, take care of your body, and keep clean. Respondents commented, “Go to the doctor… and get it treated… and it, it'll be all over,” and “Be very careful in what you do, and … take care of your body.”
This study provided additional insight into the perceptions of disease and treatment of CA-MRSA among A/PIs, a population that is at risk for acquiring the infection.2 Information infrequently found in medical records or written surveys such as potential sources of infection and measures individuals took for control and prevention of infection, including self-treatment, were identified in these ethnographic interviews. Although we were able to get in-depth information from each participant, this study was limited by the small number of interviews. Challenges in recruiting individuals with CA-MRSA for participation in part due to patient confidentiality concerns contributed to the limited number of respondents. The participants were a convenience sample and predominantly male, and therefore are not necessarily representative of all A/PIs. However, this is the first study to report the use of ethnographic and qualitative methods for identifying perceptions of behavioral risk factors which contribute to acquisition of disease, including personal hygiene and having open sores/cuts.
Additionally, these findings support epidemiological studies of CA-MRSA which have identified factors for transmission such as skin to skin contact, compromised skin integrity, environmental contamination, sharing of personal items and poor hygiene.2,5,6 Emotional and physical impact of CA-MRSA infection also were explored during our study and likely are overlooked factors that clinicians and public health professionals should consider as factors that influence persons to seek treatment and communicate issues regarding prevention of disease; emotional factors were mentioned both as a barrier to seeking treatment and as a negative outcome from infection.
An additional barrier to seeking medical treatment is the lack of comprehension by respondents of the severity of their infection. This may be due in part to the perception that skin infections are quite common in Hawai‘i, and that respondents utilized home remedies as a first round of treatment. Although herbal or complimentary medicine is becoming more popular in the United States (used by an estimated 12.1% of the adult population), the authors found that a high percentage (63%) of interviewees reported self treating the infection with herbal or complimentary medicine.8 Clinicians should be aware of the reportedly frequent use of home remedies by this population, as it may potentially contribute to interactions when treatments are combined.9 If clinicians and public health professionals do not address perceptions and misperceptions of how MRSA is acquired, it will be very difficult to prevent infection, and may also delay individuals from seeking treatment.
Challenges to educating the public, including populations such as A/PIs about risk factors for CA-MRSA infection remain. Cultural and language barriers, limited access to health care, and lack of prevention and education programs contribute to poorer health among PIs.10 The data suggest that there may be a lack of comprehension and recall, as most respondents could not remember what kind of infection the clinician told them they had, or how they had acquired the infection. Use of written documents or educational materials such as a pamphlet/brochure to supplement verbal conversation with a medical provider may help with comprehension and recall. Therefore, educational materials should be prepared and delivered in a culturally appropriate way to maximize understanding and reach. In summary, this qualitative assessment allowed for the identification of unique cultural and behavioral factors in A/PIs in our study and also may provide valuable insight into the development of culturally appropriate preventive strategies for CA-MRSA and other infections.
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8. De Smet PA. Herbal remedies. N Engl J Med. 2002;347(25):2046–2056. [PubMed]
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10. The Health Care Challenge: Acknowledging Disparity, Confronting Discrimination, and Ensuring Equality. Washington, DC: U.S. Commission on Civil Rights; 1999.
Articles from Hawaii Medical Journal are provided here courtesy of
University Clinical, Education & Research Associates