The Human Immunodeficiency Virus (HIV) and Acquired Immunodeficiency Syndrome (AIDS) epidemic have become one of the most important public health problems in recent years. HIV infection and AIDS are complicated diseases. They are one of the important causes of morbidity and mortality in the world. HIV infection and AIDS influence all aspects of human life such as physical, social, emotional and spiritual. HIV and AIDS decrease the life expectancy of infected persons, creating confusion in health care systems, and helping to economic insecurity, then leading to political instability (Sowell 2004).
On a global scale, the HIV epidemic is steady remained, also with high levels of new HIV infections and AIDS deaths .Globally, between 30 and 36 million people were infected with HIV. The annual number of new HIV infections declined from 3.0 million in 2001 to 2.7 million in 2007.HIV is the fourth leading cause of death worldwide, 2.0 million people died due to AIDS in 2008 (UNAIDS 2008).
In the first decade of HIV/AIDS epidemic Asia approximately unaffected, however in the 1990, HIV/AIDS was spreading rapidly in most Asian countries. Asia is the second part of the world that has high number of people living with HIV after sub-Saharan Africa. In 2008, 4.7 million people were living with HIV/AIDS in Asia, about 350,000 people who became newly infected. In this year 330,000 AIDS-related deaths occurred in Asia (WHO Report 2009). Injecting drug use and unprotected sex (sex worker) are the main modes of HIV transmission in Asia (UNAIDS 2008).
Iran with the population about 70 million is one of the Middle East countries in Asia, The first case of HIV was reported in 1987. According to the recent report from Iran, in 2004, there were officially 6,532 Iranians living with HIV/AIDS, of which 95% were males. The number of infected was increased to 20,130 HIV positive individuals (92.9% males) in 2007.
The estimated of HIV infected patients are about 86000 individuals. A total of 66.7% of AIDS patients are intravenous drug users, while 9% are infected by sexual contact. There are some (17%) of cases were grouped under "unspecified" route of transmission. It is feared that the HIV/AIDS situation in Iran may be more serious than these published data indicate, and the main concern is the potential spread of infection (Iran CDC 2009).
Increasing number of people living with HIV/AIDS has influenced healthcare sectors. Nurses play critical role to care of HIV positive patient. Health professionals refused to face to HIV/AIDS patient because they have fear of being infected at workplaces. Irrational and discriminatory treatment of HIV/AIDS patient is the result of health professionals fear (Eisenberg 1986 ; Adebajo et al 2003). Unfortunately, most of health professionals have this kind of perspective and practice about people living with HIV/AIDS. Healthcare providers especially nurses, general physicians and laboratory technicians are concerned about care of HIV-positive patient (Aghamoalemi et al 2009). Nurses must understand the facts and the realities of HIV/AIDS. Inadequate HIV/AIDS knowledge regarding etiology and modes of transmission may affect perceptions, thoughts, attitudes and actions of nurses in caring for these patients. Nurses reaction are varied about patient with HIV/AIDS, from positive appropriate care to inadequate isolation techniques, minimal contact, and even refusal to care for these patients (Walusimbi et al 2004).
Educational and occupational training programs have led to decrease the fear and lack of knowledge about AIDS/HIV transmission. For planning and evaluating nursing care, it is necessary the truth about disease be identified. Also inadequate knowledge is probably dangerous in nursing interventions and leading to both extreme positive or negative events and wasted resources (Unwakwe 2000). Proper knowledge base about HIV/AIDS with sufficient understanding of patients needs can help relieve fear and anxiety associated with care of patients with HIV/AIDS. Appropriate knowledge and understanding can promote quality care of these patients (Lohrmann et al 2000). A knowledge shortage about HIV/AIDS nursing care can affect outcome of care for HIV/AIDS patients.
Most of previous studies have showed negative attitude of nurses towards caring HIV/AIDS patients. One factor that cause to negative attitude is fear of being affected by occupational exposure in contact with HIV/AIDS patients. Social stigma is the second factor affected nurses attitude in contact with HIV/AIDS patients. Thus, negative attitude cause to poor management of PLWHAs who need support, treatment and care (Baylor&McDaniel 1996).
It is important for healthcare workers to be knowledgeable about HIV/AIDS prevention and treatment. Nurses should obtain updated HIV knowledge, face and come to terms with their own fears and attitudes, and gain an ability and confidence in caring for people living with HIV/AIDS. Nurses feelings and beliefs about PLWHAs can influence nurses behaviour, So, affect the quality of care delivered.
The research will be carried out at Golestan hospital in Ahvaz. Ahvaz is one of the big city in south of Iran with a population about 1,338,226 people (according to last census 2006). Golestan hospital is one of big university hospital in Ahvaz with 750 bed and 1786 staff. It's included of several units such as Emergency, Surgery, Ortopedy, Internal, Infection disease, ICU, CCU, Nephrology, Dialysis, Urology, E.N.T , Neurology, ect. Nurses in hospital are frontline provider of care for patients, particularly HIV/AIDS patients. Therefore, it is important that all nurses have a strong basis in HIV/AIDS knowledge and positive attitude to prevent new infection and to treat PLWHAs. Nurses in hospital need to be equipped with sufficient knowledge to protect themselves while helping patients with HIV/AIDS.
1.1.1 Research Justification:
The HIV/AIDS epidemic has spread rapidly in many countries in Asia, also in Iran. According to the annual case reports on HIV/AIDS, the number of reported HIV/AIDS cases is increased in Iran. PLWHA often experience extreme negative attitudes from health care profession in Iran. In previous research studies, healthcare professionals expressed their fear and unwillingness to care for PLWHA (Al-Ma'aitah et al 1996).
Number of HIV/AIDS patients increasing in Iran and they need health services. Nurses are frontline in care of such patients in hospitals. Nurses must have enough knowledge in care of these patients. But most of nurses in Iran have a knowledge shortage about HIV/AIDS, It can affect outcome of care for HIV patients. HIV/AIDS patients usually experience stigma and discrimination behavior by their healthcare workers in Iran.
Until now, various studies were exploring the knowledge and attitude of healthcare providers towards HIV/AIDS patients in developed and developing countries, "but little is known from Iran as a religious country where the study about AIDS can be regarded as a sensitive topic" (Montazeri et al 2005). There is no study about knowledge and attitudes of nurses towards care of HIV patients in this hospital and city.
The number of HIV/AIDS patients are increasing everyday and this disease don't have an effective vaccine or treatment. Education, identify modes of transmission and prevention methods are only ways for prevent of spreading the disease (Melby et al 1992).
As the mentioned above, research in the field of health provider and nurses knowledge and attitude towards HIV/AIDS and how to maintain their health in the community can determine Requirements and priorities and educational facilities. Nominating the educational requirement is one of the important factors in order to plan a suitable program. Maybe, the result of this research can help managers to plan appropriate educational program.
Nursing research studies need to be conducted to ensure nurses provide quality of care. These studies must focus on acquiring new knowledge about HIV/AIDS that are beneficial to nursing practice, decreasing the incidence of new cases of HIV infection, as well as, promoting quality of care of people living with HIV/AIDS.
1.2 Conclusion
This chapter summarized a background of HIV/AIDS. It showed the estimated number of HIV/AIDS patients in the world, Asia and Iran. It's talked about the HIV modes of transmission and its discussed nurses knowledge and their attitudes toward care of HIV/AIDS patients. Also it's discussed the justification of study that will be done in Ahvaz Golestan hospital.
CHAPTER 2
LITRETURE REVIEW
2.1 Introduction
This chapter is discussed about the knowledge and attitudes of nurses towards care of HIV/AIDS patients. Also talk about some factor affect the level of knowledge among nurses and their attitudes towards care of HIV/AIDS patients. This is argued the role of education and training programs towards HIV/AIDS in improving nurse's knowledge and attitudes. It is described the effect of occupational exposure at workplace on nurses attitudes towards care of HIV infections and AIDS patients.
2.2 Literature review
2.2.1 Knowledge and attitudes of nurses toward care of HIV/AIDS patients
Most of studies about HIV/AIDS knowledge and attitudes of healthcare worker have shown the lack of knowledge about HIV transmission and risk prevention with fear of contagion (Kohi & Horrocks 1994; Adelekan et al 1995; Lohrmann et al 2000; Mbanya et al 2001; Oyeyemi et al 2006).
Servellen et al. (1988) surveyed 1200 Registered Nurses, their result showed quarter of nurses refrain to care of HIV/AIDS patients. Thirty percent of nurses had a moderate discomfort experience in care of such patients. While just ten percent of nurses accepted care of HIV/AIDS patients. In the study was done with Gallop et al. (1989) among 700 nurses, they found that half of nurses want that HIV/AIDS patients must quarantined and about 40% of them preferred to avoid care of AIDS patients.
Walusimbi & Okonsky (2004) in their study found that 95% of nurses had experience in care of HIV/AIDS patients.47% of nurses had Fear of contagion. Those who knowledgeable had less Fear of being affected and had more positive attitude towards care of HIV/AIDS patients.
Findings about the other study showed nurses providing care for a lot of HIV/AIDS patients. HIV/AIDS knowledge was moderately adequate among nurses. Factors associated with knowledge in this study were Professional rank, frequency of care and training. Nurses' attitudes were mainly positive. Previous training and ward allocation were associated with nursing attitudes (Dellobelle et al 2009).
Aghamoalemi et al. (2009) surveyed study about the attitudes of healthcare providers towards caring of patients with HIV/AIDS in Bandar Abbas, south of Iran. Results had shown fairly positive attitudes. Findings showed that more favourable attitudes of laboratory technicians compared with nurses and physicians. Physicians had less fear of contagion. More favourable attitudes were found among who had bachelor degree.
In the study about "experience of stigma in healthcare settings among adult living with HIV in Iran" result showed that approximately all respondents had experience of stigma and discrimination from healthcare worker. This is showed most of healthcare worker had a fear of being infected with HIV when they provide care for HIV/AIDS patients. Most of respondents is experienced refusing or delaying to care from health care worker (Rahmaty et al 2010).
Rondal et al. (2002) found that both the nursing staff and the nursing students expressed empathic attitudes towards HIV-infected patients. They had less fear of HIV contagion. The findings also showed 36% would refuse from caring for HIV-infected patients.
Kermode et al. (2004) reported healthcare workers generally had a positive attitude to caring for people with HIV. However, most of them concerns about providing care. Having experience for care of HIV/AIDS patients was strongly associated healthcare workers willingness to provide care for HIV patients. HIV knowledge about mode of transmission and perception of risk were not associated with willingness to provide care for HIV/AIDS patients.
Juan (2004) founded two hundred and ten nurses (19.3%) were seriously leaving nursing because of fear of contracting AIDS/HIV. Taiwanese nurses in this study had knowledge shortage in their practice. Concerns and fears might be related to lack of HIV/AIDS knowledge.
The findings of the study was done in Yasuj(Iran) conducted by Nobandegani et al. (2003) showed that most of healthcare workers (72.9%) had a good knowledge about HIV/AIDS. However, a few of them had a positive attitude about HIV/AIDS patients.
Steele (1995) reported particularly majority of healthcare workers hold negative beliefs and attitudes. They have inadequate knowledge about HIV/AIDS. This misguided perceptions regarding risk of HIV/AIDS caused to discriminatory care of HIV positive patients.
Wang et al. (2007) looking at 1079 Taiwanese nurses. They found that those who were single and those who have higher level of education had less fear of being affected and more positive attitudes towards HIV/AIDS patients.
Westburg and Guindon (2004) discovered respondents had high hope levels when working with HIV patients. About thirty five percent of them had hopeful expectations for patients infected with HIV. Majority of them did not have negative attitudes toward or uncomfortable feelings when working with HIV/AIDS patients. More positive emotions found in their experience than negative emotions when they worked with HIV/AIDS patients.
Fernandez et al. (2004) reported in their study that nurses as compare with auxiliary workers had more positive attitudes toward HIV patients. Only twenty percent nurses had a negative attitude. They found that age and occupation were the important variables that affect on attitudes toward HIV.
Baylor & McDanial (1996) found nurses who had experience in care of HIV/AIDS patients had more positive attitudes regarding use of health care services by HIV/AIDS patients than those who have not cared for HIV/AIDS patients. Also most of nurses had a fear and concern in caring for patients infected with HIV.
Martin & Bedimo (2000) looking at 1291nurses, midwives and physicians about caring of PLWHAs. Result indicated a highly supportive attitude toward PLWHAs about empathy and avoidance factor. The respondents didn't have fear of being affected at workplace. 18% of respondents showed that they would not provide care for HIV/AIDS patients. Healthcare worker who didn't have HIV/AIDS patients had four times more likely to refused care of this patients and they refer patients to those who had one or more HIV/AIDS patients.
Most of Studies showed that socio demographic factors and other work characteristics have affected nurses knowledge towards HIV/AIDS and their attitudes towards patients with HIV/AIDS. In the study by Askarian et al. (2006), which was conducted among nursing staff in Iran had found that knowledge level about HIV infection among registered nurses was higher than auxiliary staff nurses. Women had more agree about it is impossible to identify HIV patients during the early stage of disease by their appearance than did men.
In a study in Cameron, the grade of staff affect on nurses HIV/AIDS knowledge level, that higher grade staff tend to have higher level of knowledge. Also younger nurses seemed to be more knowledgeable compared to older nurses (Mbanya et al 2001).
2.2.2 Occupational exposure of HIV infection among nurses
The healthcare worker population are about 35 million people worldwide. They are 12% of the working population in the world. The mistaken belief exists that the healthcare industry is "clean" and without hazard, when in fact there is a lot of chemical and blood-borne exposures exist and it can be career- and life-ending (Wilburn et al 2004).
Each year about 3 million health care workers are exposed to bloodborne viruses. Most of occupational exposures (about 90%) occur in low-income countries, and most of them could be prevented. In nearly all occupationally acquired infections blood is the source of the exposure. Needle sticks or cut with medical sharp tools infected with infectious patient's blood and contact of mucous membranes (for example mouth, eyes and nose) with patient's blood are the occupational exposure at workplaces (Vranes et al 2006).
Health care workers are the main group in care of PLWHA more than other profession in society. Particularly, nurses are in front line of care-givers who have continued and long contact with such patients. In fact, there is no sufficient cure or vaccine for HIV/AIDS, nursing care consists of providing wide physical care and representing emotional support to persons suffering from HIV/AIDS (Smit 2005).
Most of studies showed that, lots of nurses had experience of occupational stress, exhaustion and symptoms of occupational burnout because they provide serious care for PLWHA. Nurses occupational stress can exacerbate their fear of HIV transmission from accidental occupational injuries and exposure to mucus membrane of infected person (Gala et al 1993, Gueritault et al 2000, Nursing Standard 2002). Also, Durkin and Rondahl concluded in their studies that most of nurses have fear of contracting HIV through occupational exposure (Durkin 2004 ; Rondahl et al 2003).
In the 2002, 24,844 HIV/AIDS cases among adults reported who had experiencing of working in health care centers. Nurses comprised 21% of the healthcare personal with HIV/AIDS (CDC report 2003).
According to CDC report 2001, the average risk of HIV transmission has been estimated to be about 0.3% (95% CI = 0.2%-0.5%) after a percutaneous exposure to HIV-infected blood and after a mucous membrane exposure, approximately 0.09% (95% CI = 0.006%-0.5%). Base on CDC prevention methods, "Healthcare worker should imagine that the blood and other body fluids from all patients are infectious. They should follow infection control precautions at all times. These precautions include:
1. The routine use of barriers (such as gloves and/or goggles) when anticipating contact with blood or body fluids.
2. Washing hands and other skin surfaces immediately after contact with blood or body fluids.
3. The careful handling and disposing of sharp instruments during and after use" (CDC report 2002).
The fear of contracting HIV infection through occupational exposure impacts on the development of a professional relationship with persons with HIV infection or AIDS (Froman, &Owen 1997).
Dellobelle et al. (2009) in their study showed that lots of nurses concerned about occupational exposure. They had a fear of being affected through occupational exposure. Also result of the other study found that nurses concerned about providing care for PLWHA, and most of them believed that the risk of occupational infection with HIV to be high (Kermode et al 2005). 74% of Henry respondents scored high on stress, perceived risks and discomfort scales due to working with HIV/AIDS patients (Henry et al 1988).
Polgar (2000)in his study examined HIV risk perception based on a survey of hospital nurses in U.S. cities. He concluded nurses usually faced to the risk of transmitted HIV at workplace, particularly in caring for HIV/AIDS patients. AIDS care experience, knowledge of transmission modes, comfort with AIDS patients and working conditions are some factors associated with Occupational HIV risk perception. Nurses with less AIDS care knowledge and experience are more worried about HIV.
Askarian et al.(2007) conducted a study among 1555 registered nurses in Fars Province, Iran. Result showed that Iranian nurses had a high prevalence of needle stick injuries. 49.6% of the respondent had at least one sharps injury, about 52.3% of this classified as needle stick injuries. A hollow-borne needle was high-risk injuries (72.2%) among nurses.
Kermode et al.(2005) surveyed 266 registered nurses in India, 91% of participants believed that they are at high risk of occupational injuries. 60% of nurses perceived that an HIV-contaminated needle can cause HIV infection through needle-stick injuries.
Some earlier studies have showed many developing countries have had lack of protective equipment and safe needles that can explain risk of occupational injuries among nurses (Gershon et al 1995; Fredrich et al 2005). In Uganda, lack of safety equipments and high ratio of patients to health care workers in hospitals because of low expenditure on health care is increased risk of occupational injuries and blood borne infections for health care workers ( Fredrich et al 2005).
2.2.3 Role of education and training programs towards HIV/AIDS in improving nurses knowledge and attitude
An appropriate HIV/AIDS education programmes can change the nurses attitudes toward care of HIV/AIDS patients. As a result of different levels of concerns of health care workers, educational programmes have to meet the requirements of specific health care groups, such as nurses.
A number of studies have found that a fear of contamination with HIV primarily is related to inadequate knowledge regarding AIDS (Gallop et al. 1989; Snowden 1997; Sowell et al. 2004; Liljestrand P 2004).
In the study that was done in Chinese nurses to examining the effect of a multifaceted HIV/AIDS educational intervention on the knowledge and attitudes of nurses in caring for patients with HIV. Result showed before workshop, knowledge levels were moderate among nurses, while attitudes and willingness to care for HIV/AIDS patients were neutral. However, after workshop participants scores improved on all three variables (Williams et al 2006).
Turner et al.(1988) in their study held 5-hour seminar about HIV/AIDS among hospital nurses for improving their HIV/AIDS knowledge and infection control methods, also their attitudes in care of HIV/AIDS patients. Result showed significant change in AIDS knowledge, infection control, and attitudes toward caring for patients with HIV/AIDS for who attend in the seminar.
The result of the other study showed that AIDS training programs can decrease fear of contagion and negative attitudes towards care of HIV/AIDS patients ( O'Donnell et al 1987). Also Pisal et al.(2007) in their study among nurses showed the same results.
In Iran, Ghorbany et al.(2005) have shown that 46.5% of nurses had a low level of knowledge about HIV infection and 49% of respondents had negative attitudes toward care of HIV/AIDS patients before the workshop. Knowledge score improved about 61.4% among nurses after workshop. Also attitudes toward caring for HIV/AIDS patients were significantly promoted after workshop. Authors concluded that education training programs is necessary in improving nurse's knowledge level and more positive attitudes .In the other study among nurses, the authors showed that HIV knowledge was improved significantly from pre-test to post-test (Nyamathi et al 2005).
In 2005, Kermode et al in their study concluded that 60% of nurses perceived that an HIV-contaminated needle can cause HIV infection through needle-stick injuries. 78% of respondents believed that caring of HIV/AIDS patients must be separately from other patients. These result showed majority of nurses had a lack of knowledge and they need educational training program for improve their knowledge.
In the study that was done among 371 registered nurses in hospital, the results showed that after 6-days training program HIV/AIDS knowledge was promoted in all dimension involving treatment, care, some issues related to confident and consent. Also fear of contact with PLWHA was decrease significantly (Pisal et al 2007).
In the other study among nurses by Harnett et al.(1987) had resulted a significant improvement in HIV/AIDS knowledge and level of confidence, with reduce fear and negative attitudes associated with caring patients who have AIDS, for who have attend a lecture session with question and answer.
The result of other study showed that nurses attitudes toward care of HIV/AIDS patients is not affected of education background (Baylor et al 1996). Also Martin et al have shown experience in caring HIV/AIDS patients was more important than role of education in determine nurses attitudes (Martin et al 2000).
2.3 Conceptual framework
The conceptual frame work explains the aspects investigate in this study. The knowledge level of respondent toward care of HIV/AIDS patients, also their attitudes toward caring of such patients will study among nurses in the hospital. This main outcome is affected by several factors which are presented in the figure 1.1.
According to literature review, knowledge and attitudes of nurses towards care of HIV/AIDS patients seems to be affected by several factors such as age, educational background and marital status ect. Also affected by nurses work characteristics such as their specialization, duration of work and working hour per week ect.
Other mediatory variables are education training programs and their experience in taking care for HIV/AIDS patients. An appropriate training program for nursing staff may increase their knowledge about the nature of disease and self protective methods to reduce the infection in hospital. Through these education programs may improve their knowledge about care of HIV patients. Also throughout the education program may change the negative attitudes of nurses towards HIV/AIDS patients. Having experience in care of these patients may promote nurses knowledge in care of HIV/AIDS patients. Also it's influenced attitudes of nurses in caring of HIV/AIDS patients.
