Healthcare Workers' Attitude Towards People Living With HIV

doi:10.21203/rs.3.rs-4438428/v1

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Healthcare Workers' Attitude Towards People Living With HIV

https://doi.org/10.21203/rs.3.rs-4438428/v1

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Background: HIV-related stigmatization among healthcare workers is still high. The aim of that research was to determine attitudes and behaviors towards people living with HIV (PLWH) to determine the ratio of stigmatization and prejudice towards PLWH among healthcare workers.

Methods: This was a single-center, national, cross-sectional, prospective, analytical survey study. Doctors and nurses at Izmir Bozyaka Training and Research Hospital were included in this study. The study was performed as a face-to-face and online survey. The sociodemographic data form and AIDS Attitude Scale (AAS) were administered to the participants. The results were analysed with the IBM SPSS 24.0 program. The significance level was accepted as p<0.05.

Results: A total of 404 people were included in our study.A total of 301 (74, 5%) of the participants were female, and 13 (25, 5%) were male. The average age of the participants was 33.25 ± 8.22 years. Most of the participants were aged 24-30 years (55, 9%), and the attitudes of healthcare workers towards PLWH increased with age. Compared with assistant doctors and nurses, specialist doctors have more positive and empathetic attitudes and less avoidance.

Conclusion: Participant attitudes towards PLWH are generally mild-high positive, but negative attitudes towards PLWH are common among healthcare workers. Regular education is needed for nurses and assistant doctors to increase confidence in HIV and reduce negative attitudes towards PLWH. However, additional quantitative studies are needed to identify interventionable points to increase empathy toward PLWH.

Sexual & Reproductive Medicine

Medical Ethics

HIV

Attitude

Medical staff.

Implications for policy makers:

-The negative attitudes of healthcare workers were related to age, department type, profession, diploma degree, and having or not having HIV-related education.

-Regular education provided to nurses and assistant doctors can increase awareness and reduce negative attitudes.

Implications for the public: Healthcare workers have responsibilities to the public. According to our study's results, policy makers can take action, and we can provide an equal healthcare supply for PLWH.

HIV is a retrovirus whose source is nonhuman primates (1, 2). Despite technological advances and improvements in HIV management, HIV is still a global public health problem. According to current data, 40.4 million people worldwide are living with the virus. In 2022, 630,000 people died from HIV-related causes, and 1.3 million people were infected with HIV, 130,000 of whom were children aged 14 and under (3). Although the level of social awareness has increased worldwide, PLWH are still stigmatized and marginalized in terms of service provision (4–9). The stigmatization of PLWH is a barrier to treatment and impairs the health and quality of life of individuals (4–6, 8–11). In addition to the global impact of HIV, being diagnosed with HIV has many devastating effects on individuals. These devastating effects negatively affect the general well-being of PLWH and constitute an obstacle to accessing treatment. In addition to the devastating effects of being diagnosed, stigmatization is one of the most important factors that pushes PLWH to isolate, to avoid treatment and testing, to stop antiretroviral therapy (ART) and even to commit suicide (4). Various studies have shown that stigmatization and discrimination are often perpetrated by family members, siblings and relatives (6, 12). Stigmatization and discrimination against PLWH were also reported to be perpetrated by neighbors, friends, and colleagues and often manifested as rejection, neglect, avoidance, ridicule, verbal abuse, insult, and humiliation (6, 13). In brief, the stigmatization of PLWH is a barrier to treatment and impairs the health and quality of life of individuals (4–6, 8–11).

This study was conducted to determine the attitudes and behaviors of healthcare professionals towards PLWH to determine the levels of prejudice and stigmatization, to measure their level of knowledge about HIV, and to determine the reasons for negative attitudes towards PLWH in line with these data.

Participants and Sampling

There are 760 nurses at Izmir Bozyaka Training and Research Hospital, 397 assistants and 197 specialists. A total of 317 people were calculated with a 95% confidence interval and 5% margin of error with a sample calculation for a certain population. The stratum weight was 0.17, and a study was planned to include 96 assistant 63 specialist doctors and 158 nurses. The study was planned as a single-center, national, cross-sectional, prospective, analytical survey study. Our study was approved by the Izmir Bozyaka Training and Research Hospital Clinical Research Ethics Committee (Decision number: 2023/163) on 14.09.2023. Our study was conducted between 20 September 2023 and 01 February 2024 by administering a face-to-face or online questionnaire to doctors and nurses working in this hospital after they were informed about the study. This study included 404 participants, including 178 assistants, 65 specialists and 161 nurses, by evaluating the responses of employees working at Izmir Bozyaka Training and Research Hospital who voluntarily agreed to participate in our study.

Questionnaire

The questionnaire used in our study consisted of 2 parts. The first part, which was prepared by reviewing the literature, consisted of 6 questions about the descriptive characteristics of the participants (age, sex, educational status, position in the unit where they work, the unit where they work, the number of HIV (+) cases they see per year, etc.) and 9 questions measuring the level of education and knowledge about HIV (7, 8, 11, 14). In Part 2 of the questionnaire, the AIDS Attitude Scale (AAS), which was developed by Froman et al. in 1992 and whose Turkish validity and reliability analysis was conducted by Karabulut and Gürçayır, was used. The Turkish version consists of 21 items and 2 factors (avoidance and empathy), as in the original version (15, 16). This scale is used to determine individuals' attitudes towards PLWH. The 21 items in the AAS consist of two subdimensions, namely, avoidance (14 items) and empathy (7 items). The assessment is carried out on a Likert-type scale ranging from 1 to 6; this scale includes a rating from "Strongly disagree" (1) to "Strongly agree" (6). Subdimension mean scores are calculated by dividing the sum of the scale items in the relevant subdimension by the number of items. A low mean score for the avoidance subscale (AS) and a high mean score for the empathy subscale (ES) indicate that individuals have more positive attitudes towards PLWH.

A summary score ranging from − 5 to + 5 was obtained by subtracting the mean AS score from the mean ES score. In this scoring approach, negative scores reflect negative attitudes towards PLWH, and positive scores reflect positive attitudes. The Cronbach's alpha coefficient, the internal consistency coefficient of the Turkish-adapted scale, of the AAS was 0.88. In addition, the test-retest and test-retest internal reliability coefficients of the subdimensions were 0.85 and 0.86, respectively. The validity and reliability coefficient (Cronbach's alpha) were measured as 0.83 for AS and 0.75 for ES.

Explanatory Variables

The explanatory variables included a range of sociodemographic variables, such as sex, age, marital status, diploma degree, profession, department type, having HIV-related education, and access to PEP.

Data analysis

All the statistical analyses were performed using IBM SPSS Statistics 24.0 statistical software. The chi-square test, Fisher's exact test, Fisher’s Freeman Halton test and continuity (Yates) correction were used for comparisons of qualitative variables. These tests are widely used to assess the relationships between categorical data. In cases where the data were normally distributed, parametric analyses such as independent sample t tests, ANOVA tests, and the Games–Howell test were used. These tests were used to compare means between groups and were based on the assumption that the data were normally distributed. However, when the data did not fit a normal distribution, nonparametric tests such as the Mann‒Whitney U test and Kruskal‒Wallis H test were used. These tests are used to compare median values between groups and do not require the assumption that the data are normally distributed. The results obtained were considered to be statistically significant at a significance level of p < 0.05.

The sociodemographic characteristics of the participants are presented in Table 1. The mean ± standard deviation (SD) age of the participants was 33.25 ± 8.22 years. When age was analysed according to age, it was found that most participants were aged between 24 and 30 years (55.9%). Most participants were women (74.5%), single (52%), or assistant doctors (441%).

Most participants had a Master of Science or associate degree (46.29%), had provided care to at least one PLHIV in a year (61.3%), and had not received HIV-related training in one year (80%).

When the participants were analysed according to their units, 74.5% worked in internal units, 18.3% in surgical units and 7.2% in basic branch units. A total of 36.9% of the participants stated that they had sufficient knowledge about HIV/AIDS. While 81.4% of the participants stated that there are decisions and regulations taken to protect the rights of PLWH, 90.7% of those can access prophylaxis. Only 20.0% of the participants stated that they had received training on HIV or the rights of PLWH in the last year. When the data showing the number of HIV cases encountered within a year were analysed, 38.7% of the participants stated that the number of cases they encountered was zero (Table 1).

The findings are presented in Tables 2 and 3. Age between 24 and 30 years, working in internal or surgical units, working as a specialist doctor, working as a master's degree and working in HIV-related education in the last year were found to be associated with positive attitudes (Table 3).

: In this study, it was generally observed that the participants did not exhibit discriminatory attitudes towards PLWH and that the attitudes of the participants were positive at a medium-high level. However, it was observed that there are still negative attitudes towards PLWH among health professionals. In a study conducted in Indonesia, it was observed that many health workers exhibited negative attitudes towards PLWH (14). Studies conducted in the southern United States (USA) and Iran have shown that HIV-related stigma and discrimination in health care delivery are still common (8,11). Similarly, in another study conducted in another region of the USA, it was concluded that HIV-related stigmatization still exists among healthcare professionals (17).

In this study, no statistically significant difference was found between sex and the level of stigmatization towards PLWH. In a 2017 study conducted by Stringer et al. in the southern United States of America using another stigma scale, it was found that men had significantly greater levels of stigmatizing behaviours (8). In the study of Spence et al., men were more discriminatory (17). The results of studies conducted in Iran and Indonesia are similar to those of our study (11,14).

The 24-30 age group had a significantly greater positive attitude towards PLWH than did the 31-40 age group. As age increased, the participants tended to become negative in terms of their attitudes and approaches towards PLWH. Healthcare workers with the most empathetic attitudes towards PLWH were aged 24-30 years. These findings are different from the results of studies conducted in the southern USA in 2016 and in Indonesia in 2023 (8,14). Although no significant differences were found between the sociodemographic data and stigmatization scores in these studies, in a study conducted in Iran, the stigmatization scores of participants aged 50 years and older were found to be significantly greater (11). It should be kept in mind that the age group in our study differed from the age categories in this study and that there were differences in age, culture and education between the healthcare professionals in the two countries.

It was observed that healthcare workers with a specialist doctor status had more empathic attitudes and fewer avoidance tendencies than did those with an assistant doctor and nurse status. In a study conducted in Indonesia with 8 doctors, 200 nurses and 44 midwives using a different scale, unlike our study, it was found that doctors had a high level of HIV knowledge and a high level of HIV-related stigma (14). This difference may be due to the small number of doctors included in that study (8 doctors) compared to our study and cultural differences between the two countries. In another study conducted in Nigeria, doctors exhibited more stigmatizing attitudes than dentists and laboratory personnel did. In a study conducted in Iran, the findings were in parallel with the findings of our study (11). These results suggest that the professional status of healthcare workers may affect their attitudes towards PLWH. In particular, the differences in empathy and general attitudes between nurses and specialized doctors are striking.

The degree of education had a determining effect on the attitudes, empathy levels and avoidance tendencies of the participants towards PLWH. In particular, the attitudes of healthcare workers with a master's degree toward PLWH were more positive than those toward PLWH with a bachelor's degree. These findings are in parallel with those of a study conducted in Iran (11). In studies conducted in the USA and Indonesia, unlike our study, no significant relationship was found between diploma degree and stigmatization (8,14).

A total of 36.9% of the healthcare workers stated that they had adequate knowledge of HIV/AIDS. Moreover, the fact that only 20.0% of the participants stated that they had received training on HIV or the rights of PLWH in the last year reveals the lack of training on HIV among health workers in a concrete way. The fact that the rates of the participants' feelings of self-sufficiency and the rate of receiving training are similar led the researchers to think that the prerequisite for self-confidence is education. In a study conducted with 95 nurses, 69.5% of the participants stated that they had sufficient knowledge about HIV/AIDS. Compared to the participants in our study, the participants in that study were more knowledgeable about HIV, but when asked about HIV transmission, a total of 25 people chose the options of handshaking-kissing, skin contact, and being in the same environment, which would not be transmitted (7). Similarly, when the participants were asked about ways to protect themselves from HIV, 15 people were asked to choose the option of avoiding touching PLWH and not being in the same environment as PLWH. This comparison showed that practices should be implemented to increase both the level of knowledge and self-confidence of healthcare workers about HIV.

In another study using a different scale, 65.1% of the participants did not receive formal HIV education. In the same study, it was found that the stigmatizing behaviour of the participants was associated with low HIV knowledge, fear of being infected with HIV and the HIV unit where they worked (14). In a study conducted in Iran, in parallel with these findings, it was found that being educated about HIV and other blood-borne diseases was associated with a lower stigma score (11). In a study conducted by Whiteside-Mansell et al. in 2020, a low level of knowledge about HIV was observed among health personnel to increase discrimination, prejudice against PLWH and the risk of perceived stigmatization in service delivery practices (5). In a study conducted by Hidayat et al. in Indonesia, the high stigma attitudes of nurses and midwives were found to be associated with low HIV knowledge. In the same study, another finding that contradicts this result is that the doctors who participated in the study had both the highest HIV knowledge score and the highest stigmatizing attitude score (14). In the study conducted by Stringer et al. in the southern USA, no difference was found between education, age and occupational category variables or stigmatization scores, in contrast to the data in our study (8).

However, the attitudes of the participants who had received training on HIV or the rights of PLWH in the last year were more positive than those who had not, and education plays an important role in reducing stigmatization and avoidance of PLWH due to fear of contracting HIV. In parallel with the results of our study, previous studies have shown that having a high level of knowledge about HIV transmission leads to less fear of PLWH and thus lower stigmatization. People with little education and little knowledge about HIV have more stigmatizing attitudes (11). HIV education positively affects the attitudes of health personnel towards PLWH. Training is effective at improving HIV prevention and general attitudes towards PLWH. In contrast to these findings, in the study of Stringer et al., it was found that receiving stigma-specific training in the last year was not a significant determinant of stigmatization behaviour in units where there are laws on HIV-related stigma, regardless of whether they have sanctioning power (8).

In our study, 81.4% of the participants stated that they knew of the existence of regulations to protect the rights of PLWH, while 90.7% of those who could access PEP did. In the study of Stringer et al., the rate of access to PEP was 23.5%. In the same study, the stigmatization scores of healthcare workers who did not have access to PEP or who were not aware of PEP were significantly greater than those who were aware of PEP. It was found that the stigmatization attitudes of employees working in units where laws related to HIV-related stigmatization do not have sanctioning power were greater (8). These data show that the rate of access to PEP was high in our study. The majority of the participants were aware of the regulations to protect the rights of PLWH, but the rate of receiving training on HIV or on protecting the rights of PLWH was low.

When the data showing the number of HIV cases encountered within a year were analysed, 38.7% of the participants stated that the number of cases they encountered was zero. On the other hand, 61.3% of the participants stated that they had encountered at least one HIV case. This situation shows that the majority of healthcare workers have encountered at least one HIV case within a year. When the attitudes of the participants towards PLWH were evaluated according to whether they had encountered HIV cases during the year, no statistically significant difference was found. This finding shows that participants' exposure to HIV does not have a direct effect on their attitudes towards PLWH. In parallel with our study, Stringer et al. reported that the HIV case load was not a determinant criterion of stigmatization behaviors (8).

The responses to the questions on HIV transmission and protection given to the participants in our study showed that skin-to-skin contact and kissing, in which HIV cannot be transmitted, are still considered situations in which there is a risk of transmission among healthcare workers, albeit in small numbers. Evidence-based data should be disseminated to all healthcare workers, and those myths that cause stigmatization and unnecessary fear among the public should be dispelled.

A total of 76.7% of the participants stated that they were not aware of the anonymous HIV testing laboratory within Izmir Municipality. After being informed about this center, 86.4% of the participants stated that they could refer to it. The fact that many healthcare workers are still not aware of this service has revealed the need for the promotion of such important health services and the dissemination of information to a wider audience.

The avoidance attitudes of the participants working in basic units were greater than those of participants working in other branches. It is thought that participants working in basic health sectors (blood sampling, biochemistry, pathology, microbiology) tend to avoid such situations since it is thought that the risk of HIV exposure may be greater than that in other sectors. In a study conducted in Iran, it was observed that dentists and laboratory personnel who had frequent contact with blood and other body fluids due to the nature of their profession exhibited greater HIV-related stigma (11). In a study conducted by Stringer et al. in the southern United States of the USA, it was found that employees working in HIV/sexually admitted disease clinics had higher levels of stigmatizing attitudes, and it was thought that this situation may have occurred due to burnout caused by seeing a large number of cases from the same patient group (8).

When the statements in the AS were analysed, the statement with the highest negative mean was "I sympathize more with patients who contracted AIDS due to blood transfusion than with patients who contracted AIDS by using IV drugs" (3,21±1,73). This shows that the participants have a high tendency to avoid individuals infected with HIV as a result of drug use, that the participants have a stigmatizing attitude towards this group and that they have less empathy towards this group. In contrast, in a study conducted in Iran, healthcare workers were stigmatized toward sexual practices rather than IV substance use. The authors of the study conducted in Iran attributed this situation to the religious and conservative structure of Iran and the fact that IV substance use is a relatively accepted phenomenon in the society in the Kerman region where the study was conducted (11).

Limitations of the Study: The study was conducted with physicians and nurses actively working at the Izmir Bozyaka Training and Research Hospital. The findings cannot be generalized to all health personnel. In addition, the limitations of the study include the status of the personnel being on leave, voluntary inclusion in the study, the ability to answer the statements according to the participants' own statements, and the fact that the majority of the participants were women.

The study revealed that attitudes towards PLWH among healthcare workers at Izmir Bozyaka Research and Training Hospital are generally mild-high positive but negative attitudes towards PLWH are still common, which indicates that HIV-related stigma reduction policies and interventions in healthcare settings in Turkey are needed. Healthcare managers need to provide frequent training and educate healthcare workers to reduce negative attitudes toward and stigmatization of PLHIV.

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Tables 1 to 3 are available in the Supplementary Files section

The authors declare no competing interests.

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Healthcare Workers' Attitude Towards People Living With HIV

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Abstract

Key Messages

Background

Methods

Participants and Sampling

Questionnaire

Data analysis

Results

Discussion

Conclusion

References

Tables

Additional Declarations

Supplementary Files

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