Attitudes of Health Care Providers to Persons with HIV/AIDS
Attitudes of Health Care Providers to Persons Living With HIV/AIDS in Lagos State, Nigeria
Sylvia Bolanle Adebajo1, Abisola O Bamgbala1 and Muriel A Oyediran2
1Department of Community Health and 2Institute of Child Health and Primary Care,
Lagos University Teaching Hospital, P.O. Box 2088, Lagos, Nigeria.
Correspondence: Dr Sylvia Bolanle Adebajo, Department of Community Health, Lagos
University Teaching Hospital, P.O. Box 2088, Lagos, Nigeria. Tel: 234 1 2600520-9 Fax:
234 1 2630431 E-mail: [email protected]; [email protected]; kunle.
Code Number: rh03013
ABSTRACT
This study was conducted to examine the knowledge, beliefs and attitudes of nurses and
laboratory technologists towards people living with HIV/AIDS (PLWA) and the factors
responsible for these attitudes. Information was elicited from 254 randomly selected
nurses and laboratory technologists from 15 government owned health facilities in Lagos
State with the use of a structured questionnaire. Results indicate that most of the
respondents (96.3%) had moderate to good knowledge of HIV/AIDS. Respondents’ level
of knowledge was influenced by the level of formal education attained, length of practice,
gender and attendance at refresher courses on HIV/AIDS (p < 0.05). In contrast,
respondents’ age, occupation and religion did not significantly influence their level of
knowledge (p > 0.05). Attitude towards PLWA was poor. Some (55.9%) of the health
workers felt that PLWAs are responsible for their illness, while 35.4% felt that they
deserve the punishment for their sexual misbehaviours. Only 52.8% of the respondents
expressed willingness to work in the same office with a PLWA, while only 18.0% would
accept to visit or encourage their children to visit a PLWA, probably because of the fear of
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contagion. It is, therefore, essential that health care providers be properly informed in
order to improve their quality of care for PLWAs. (Afr J Reprod Health 2003; 7[1]: 103-
112)
RÉSUMÉ
Attitudes des dispensateurs des soins médicaux envers les sidéens dans l’etat de Lagos.
Cette étude a été menée pour examiner la connaissance, les croyances et les attitudes des
infirmières et des techniciens de laboratoires envers les sidéens et les facteurs qui en sont
responsables. L’information a été recueillie, à l’aide d’un questionnaire structuré, auprès de
254 infermières et techniciens de laboratoire selectionnés au hasard dans 15 hôpitaux
gouvernementaux dans l’Etat de Lagos. Les résultats ont montré que la plupart des
interrogés (96,3%) ont une bonne connaissance du VIH/SIDA. Le niveau de connaissance
chez les interrogés a été influencé par le niveau de l’éducation formelle atteint, la durée de
la pratique, les sexes et la fréquentation aux stages de recyclage sur le VIH/SIDA (p <
0,05). Par contre, l’âge, le métier et la religion des interrogés n’ont pas influencé, leur
connaissance de manière significative, (p < 0,05). L’attitude envers les sidéeens était
mauvaise. Certaines (55,9%) parmi les infirmières estimaient que les sidéens étaient
responsables de leur maladie alors que 35,4% estimaient qu’ils méritaient la punition pour
leurs mauvaises conduites sexuelles. Seuls 52,8% des interrogés ont exprimé la volonté de
travailler dans le même bureau que les sidéens alors que 18.0% aimeraient visiter ou
encourager leurs enfants de visiter les sidéens probablement de peur d’être infectés. Il est
donc bien nécessaire que les dispensateurs des soins médicaux soient bien informés afin
d’améliorer leur qualité de soins pour les sidéens. (Rev Afr Santé Reprod 2003; 7[1]: 103-
112)
KEY WORDS: AIDS, HIV, attitude, health care providers, PLWA
INTRODUCTION
From the beginning of the pandemic in 1981 to date, HIV has continued to spread at the
rate of more than 10,000 new cases per day despite significant efforts made to contain its
spread.1 If this trend persists unchecked, a cumulative total of over 60 million adults
would have been infected by the end of the year 2000 with the largest number (63%)
emerging from sub-Saharan Africa.2
Nigeria, the most populous country in Africa is not spared, as the epidemic continues to
show a rapidly increasing trend with a median prevalence of over 5% and over two
million people already infected.3
With the increasing number of people living with HIV/AIDS, AIDS control and
preventive strategies must not only continue to encourage behavioural modifications by
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all, but should also highlight the need to respect the rights to care of the increasing number
of people with HIV/AIDS. In addition, there should be full integration of these persons
within the context of their families and the society at large in the most appropriate ways
that would allow them to continue to live productive lives socially and economically.4
In reality, however, the fear of being infected at workplaces, educational institutions and
in the community has led to irrational and discriminatory treatment of people living with
HIV/AIDS (PLWA). Their rights to employment, housing, education and even health and
nursing care are being violated because of their HIV status.5-7 This practice unfortunately
exists despite strong evidence from research that has revealed that non-sexual contact with
HIV positive individuals carries little or no risk.5, 8-11 This is even more so if careful
precautions with blood products are taken, as this further protects people from contracting
the infection.6,12-14
Health care providers, who are also members of the general community, are likely to elicit
similar prejudicial and fearful reactions to HIV/AIDS infected persons as members of the
community. The resultant effects of such negative attitudes include poor patient
management, with people being denied most needed treatment, care and support. This in
turn could affect their morale, self-esteem and self-determination to live quality lives
devoid of stigma, fear, repression and discrimination.15,16
Maintaining the desired quality of life of people with HIV/AIDS is possible mainly
through extensive, competent and compassionate nursing care. Yet, the provision of this
care raises health and occupational concerns for all levels of health care providers.7 There
is, therefore, an urgent need for all health care providers, particularly nurses who have
direct contact and spend more time with patients, to examine their personal attitudes
towards PLWAs, as this can compromise compassionate care.
This study is aimed at determining the level of knowledge, attitudes and beliefs of nurses
and laboratory technologists towards HIV/AIDS infected persons and to recommend
appropriate measures to address the deficiencies identified.
MATERIALS AND METHODS
This descriptive cross-sectional survey of three hundred registered nurses and laboratory
health technologists was conducted between July and September 1999 in Lagos State, the
most populous state in Nigeria. It was conducted to assess their level of knowledge of the
causes, modes of transmission and methods prevention of HIV/AIDS and their attitudes to
people living with HIV/AIDS using a well structured, self-administered questionnaire that
contained 44 items.
With permission sought from all relevant authorities, selected respondents who gave their
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full consent to participate in the study were recruited. Prior to this, they were duly
informed about the general nature and purpose of the study and their right to withdraw at
any time without prejudice to their present or future employment.
Respondents’ level of knowledge of HIV/AIDS was computed by judging their answers to
the causes, modes of transmission and prevention of HIV/AIDS. A mark was awarded for
every correct response to a set of questions and no mark was awarded for incorrect
responses. The total mark obtainable was sixteen and the levels of knowledge based on the
highest scores attainable were as follows: 0-9 = poor knowledge; 10-12 = fair knowledge;
and 13-16 = good knowledge.
Similarly, respondents’ attitude to PLWA was also assessed quantitatively judging from
the proportion of `yes’ responses to individual questions asked on how they would react,
relate or treat PLWAs. These responses were computed individually.
Sampling
From a comprehensive list of government-owned health facilities in the Lagos metropolis,
fifteen health facilities were randomly selected by simple balloting. From each selected
health facility, a list of names of nurses and laboratory technologists was obtained from
the respective medical directors. From the list, respondents were selected by stratified
sampling method using a ratio of two laboratory technologists to three trained nurses. A
maximum of 20 health workers comprising thirteen nurses and seven laboratory
technologists were recruited from each health facility.
To ensure anonymity and confidentiality, respondents in each health facility were
requested to drop their completed questionnaires devoid of personal identities into sealed
boxes provided by the study team. The questionnaires were administered and collected in
the boxes provided by the principal investigator assisted by four experienced and trained
interviewers.
Two hundred and fifty four questionnaires (84.6%) were returned at the end of the data
collection exercise. Data obtained were crosschecked for consistency and analysed using
the statistical analysis software (SAS Institute Inc, Cary, NC).
RESULTS
Two hundred and fifty four health workers comprising one hundred and four (40.9%)
laboratory technologists and one hundred and fifty nurses (59.1%) were surveyed. There
was a disproportionate sex distribution of 181 (71.3%) females and 73 (28.7%) males.
Many (56.7%) of them were aged between 30 and 39 years with a mean age of 36.0 years
(SD 6.42). Less than half of the respondents had practiced for 10-15 years with an
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average duration of 10.4 years (SD 5.64). Over three quarters of the respondents were
Christians and the majority of them had been sponsored by their health facilities to attend
at least one refresher course on HIV/AIDS.
Levels of Knowledge of HIV/AIDS
Two hundred and forty respondents (94.5%) claimed that they had seen at least one case
of AIDS. Based on a total of 16 marks, one hundred respondents (39.4%) had very good
knowledge, one hundred and forty five (57.1%) had fair knowledge, while only nine
(3.5%) had poor knowledge. A high level of knowledge of HIV/AIDS was displayed by
respondents who had higher level of formal education compared to those with lower levels
(p = 0.016). The longer the length of practice, the higher the level of knowledge (p =
0.0003); more males (40.6%) than females (37.5%) had excellent scores on knowledge (p
= 0.009); and attending a refresher course on HIV/AIDS was associated with a higher
level of knowledge (p = 0.01). In contrast, age, occupation and religion did not
significantly influence the level of knowledge of respondents (p > 0.05).
Although the overall level of knowledge of the modes of transmission and methods of
prevention was fair, there were some deficiencies and misconceptions. (Table 1)
Causes and Modes of Transmission of HIV
Over ninety five per cent of the respondents knew the causes of AIDS and correctly
identified heterosexual intercourse, blood transfusion and sharp instruments as some
modes of transmission of HIV. However, in addition to these, some respondents believed
that HIV could also be transmitted through insect bites (15.7%), hugging or touching an
infected person (9.4%), sharing the same toilet and cooking utensils with an infected
person (9.4%), and by having skin contact with an infected person (27.1%).
High Risk Target Population
People who indulge in prostitution, homosexuality and multiple sexual partnering were
correctly identified by over 90% of the respondents as groups of people at high risk of
contracting HIV. However, an appreciable proportion (50%) of the respondents failed to
identify commercial drivers, adolescents and drug addicts as other high risk groups.
Likewise, the respondents had poor knowledge of the groups of people least likely to
contract HIV. For example, 72.4% and 92.1% respectively of the respondents incorrectly
identified patients in hospital and health care providers as groups also at high risk of
contracting HIV/AIDS.
Areas of Misconception Identified
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Some degree of homophobia was detected among the respondents. Over one third of the
them felt that all homosexuals have AIDS. A large proportion of the respondents (82.7%)
did not know that women are at increased risk of contracting or transmitting HIV during
their menstrual period. A few of the respondents (18.1%) felt that AIDS is curable if
treatment is commenced early.
Although 94.5% of the respondents correctly identified blood as a vehicle of transmission
of HIV, only 81.1% and 71.7% correctly identified vaginal and semen secretions
respectively. Furthermore, 69.9%, 78.0% and 76.4% of the respondents respectively
thought that HIV can be transmitted through saliva, tears and sweat.
Attitudes of Respondents to People Living with HIV/AIDS
Two hundred and thirty eight respondents (93.7%) believed that HIV/AIDS is a serious
threat to health workers and 87% believed that treating PLWA puts them at increased risk
of contracting HIV. Many of the respondents (79.5%) believed that an HIV infected
person poses a great danger to others, 34.7% felt that HIV infected persons should be
isolated, over half (55.9%) felt that AIDS patients are responsible for their illness, and 90
(34.4%) felt that they deserve the consequences of their reckless life as a form of
punishment from God. Many (89.8%), however, felt that they do not deserve to die.
Majority (94.5%) felt that they deserve to be treated with empathy and understanding and
given the best medical care possible.
Whilst many of the respondents felt that persons with AIDS should be allowed to live
their normal lives, i.e., to continue working or schooling, 44 (17.3%) believed that they
should be relieved of their jobs and 50 (19.7%) recommended that students infected with
AIDS should be expelled from school.
The majority of respondents (91.3%) claimed that they would retain their friendship with
PLWAs, 154 (52.8%) expressed their willingness to work in the same office with an
AIDS patient and only 46 (18.0%) said they would visit or encourage their children to
visit an AIDS patient.
Attitude of Health Workers towards Treatment of HIV/AIDS Patients
Ninety three per cent of the respondents accepted that they are duty bound to treat all ill
persons irrespective of their HIV status and agreed to treat persons known to be infected
with HIV/AIDS. A lower percentage (87.4%) agreed to examine or touch them. Most of
the respondents (87.4%) advocated for the screening of all patients prior to admission into
the wards particularly those admitted for surgical procedures, but only 108 (42.5%) would
encourage the admission of PLWAs to the wards.
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Respondents’ Level of Awareness of the Universal Precautions against HIV
Two hundred and eight respondents (81.9%) were aware of and had read the universal
precautions for health workers, while only 66 (26.0%) were aware of its existence at their
workplaces. Only about half (52.4%) were privileged to attend a refresher course on HIV/
AIDS, and when asked almost all the respondents expressed the desire to attend a
refresher course on HIV/AIDS if given the opportunity.
Attitudes of Health Workers to HIV Screening
Only seventy respondents (28.0%) had been screened for HIV. Of these, 31.4% were
screened prior to blood donation, 45.7% out of curiosity or for personal interests, 17.1%
either on doctor’s advice or for routine antenatal check, and 5.7% for travel requirements.
Other respondents (72.0%) had never been screened because of fear (18.5%), high cost of
the test(s) (9.8%), and a strong conviction that they will never be infected (71.7%).
However, many of the respondents (83.5%) said they were willing to be tested if HIV
screening is provided free of charge. All the respondents unanimously agreed that HIV
screening should be made free for all health workers.
More respondents aged 30-39 years (37.5%) had been screened for HIV when compared
with 11.1% and 16.2% of those aged 20-29 years and above 40 years respectively (p =
0.0001). More male respondents (46.6%) had been screened for HIV compared to 20.3%
of females (p = 0.0003). The longer the length of practice, the less likely it was for
respondents to have been screened (p = 0.03). Also, 34.6% of the laboratory technologists
were screened, compared to 23.3% of nurses although this difference was weakly
statistically significant (p = 0.049).
In contrast, the level of formal education and religion of respondents did not significantly
influence whether or not they were screened for HIV (p > 0.05).
DISCUSSION
Until recently, HIV/AIDS control programmes in Nigeria had focused primarily on
preventing the spread of HIV through behaviour modifications. However, with the
growing number of PLWAs, there is increasing concern on the crucial role of the health
care delivery system in providing wide range of care and support. This has become
inevitable as almost every person living with HIV is bound to fall sick at one time or the
other, thereby requiring medical care from health workers who are well trained and
willing to provide such care.
The study revealed that a significant proportion (96.5%) of the study subjects had
appreciable (moderate to high scores) knowledge of the causes and prevention of HIV/
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AIDS. However, in spite of this, there existed many gaps in their knowledge of HIV and
they had various misconceptions regarding how HIV/AIDS can be transmitted. In
addition, a strong apprehension on how to handle the contagious nature of the disease was
revealed.
Most of the respondents (96.0%) knew the causative agent of AIDS to be a virus and the
main modes of transmission to be sexual intercourse, blood transfusion, sharing sharp
objects and perinatal transmission. However, there were also erroneous beliefs by the
majority of the respondents that the HIV could be transmitted through insect bites
(84.3%), touching and hugging (90.6%), sharing of toilet facilities with infected persons
(90.6%), and poor levels of health and nutrition (92.9%). Okotie et al, in their study
amongst civil servants, reported much lower figures of 36.8% and 37.9% on the sharing of
utensils and casual kissing respectively as other modes of transmission.9,17
Epidemiological studies throughout the world have reported only three main modes of
HIV transmission. One is through sexual intercourse with an infected person; second,
through exposure to blood, blood products or transplanted organs or tissues; and third,
from an infected mother to her fetus or infant before, during or shortly after birth.9,17-18
Casual contacts such as touching, hugging and kissing an infected person with HIV/AIDS
do not result in HIV transmission.18
Respondents had varied knowledge of people at high risk of contracting HIV/AIDS.
Whilst a significant proportion correctly identified prostitutes (100%), homosexuals
(93.7%), people with multiple sexual partners (94.4%), only 64.6%, 44.4% and 45.2% of
the respondents respectively correctly identified intravenous drug users, commercial
drivers and adolescents as other high risk groups. In addition, many of them did not seem
to know groups of people who are least likely to contract HIV/AIDS. For example, 92.1%
and 72.4% of the respondents felt that health workers and in-patients are at very high risk
of contracting HIV. Odujinrin et al reported much lower figures (51.5%) of health workers
who identified homosexuals as a high risk group.19
Studies have suggested that the risk of nosocomial transmission of HIV is extremely low
(0.3%) even after accidental parenteral inoculation.6,8,17,20-21 The incidence of HIV
infection resulting from needle stick injury is a rare event with only 41 cases reported
worldwide.9
Some degree of homophobia was displayed by the respondents. Ninety six of them