HIV KNOWLEDGE AND ATTITUDE AMONG NURSES TOWARDS CARING FOR HIV-POSITIVE

INDIVIDUALSINSARAWAK

Ruziana Binti Miss

Master of Puhlie Health (Health Promotion)

2010

mv KNOWLEDGE AND ATTITUDE AMONG NURSES TOWARDS CARING

FOR HIV-POSITIVE INDIVIDUALSIN SARA W AK

RUZIANA BINTI MISS

A thesis submitted in fulfillment of the requirements for the degree of

Master of Public Health (Health Promotion).

Faculty of Medicine and Health Sciences

UNIVERSITI MALAYSIA SARA W AK

2010

DECLARA TION

No portion of the work referred to in this thesis has been submitted in support

of an application for another degree of qualification for this or any other

university or institution ofhigher learning.

Signature:

b Name: RUZIANA BINTI MISS

Date: May 15, 2010

ii

DEDICATION

This thesis is dedicated to my husband, Faisal, and my children,

AnisFarahin, AzianNadiah, and Amir Ridhuan.

iii

ACKNOWLEDGEMENTS

I would like to express my deepest gratitude to my superVIsor,

Associate Professor Dr. SitiRaudzahGhazali for her guidance, patience, advice

and unconditional support throughout the project.

Thank you to Tan Sri Datu Dr. MohamadTaha bin. Arif, Professor Dr.

MohdSyafiq bin Abdullah, Professor Dr. MohdRaili bin Suhaili, and

Associate Professor Dr. Kamaluddin bin Bakar for your positive comments

and guidance.

Many thanks to Dr. Haironibt.Yusoff, and Mdm. CheahWhyeLian for

their guidance and expertise.

Thank you to Sarawak State Health Department for allowing me to

conduct this study in the clinics. A special thanks to Dr. Haji Jamail bin Haji

Muhi for his support as Kuching Divisional Health Officer during the study

period. Thank you to the Nursing Sisters for their helping hand and all nursing

staff who participated in the study.

Thank you to my friends for their words of encouragement for me to

get through the difficult moments and who have helped me so much in

completing this report. Last but not least, I would like to thank my husband,

Faisal bin Ghazali, for his unconditional support and words of encouragement.

And finally, thank you to my family for support and understanding throughout

my studies.

iv

ABSTRACT

HIV KNOWLEDGE AND ATTITUDE AMONG NURSES TOWARDS

HIV-POSITIVE INDIVIDUALS IN SARAWAK

Ruzianabinti Miss

Supportive environment is important to ensure every HIV-positive

person receives unbiased healthcare services. A supportive environment refers

not only to physical environment but also to workplace culture, and the

knowledge, and attitude of healthcare personnel toward HIV positive

individuals. Inadequate HIV knowledge and negative attitudes of nurses

towards the HIV -positive individuals has been documented to jeopardize the

service. This study aims to assess the HIV knowledge and attitude of nurses

towards HIV -positive individuals and factors associated with it. A cross­

sectional study was conducted among nurses working in 21 Maternal and

Child Health Clinics in Kuching District (N = 173). The response rate was

93.1 % (N = 161). Data was collected using self-administered questionnaire.

HIV knowledge was assessed objectively using 'yes' and 'no' answers while

attitude towards HIV~positive individuals was assessed using Likert's scale

ranging between 1 to 6 response value. The results show that the proportion of

nurses who have good HIV knowledge was 57.1 %, and 77% of nurses had

positive attitudes towards HIV -positive individuals. Despite having good HIV

knowledge, misconceptions regarding HIV transmission did occur. Periodic

and specific continuous education is reconunended together with guided

v

discussion on ethical scenarios and attitude exploration in order to achieve and

maintain adequate know ledge and a positive attitude.

vi

ABSTRAK

KAHAN DlKALANGAN JURURAWAT MENGENAI PENGETAHUAN

HIV DAN SIKAP MENGAMBIL BERAT TERHADAP PENGIDAP HIV­

POSITIF DI SARA W AK

Ruziana binti Miss

Persekitaran yang baik adalah sangat penting bagi pengidap HIV-positif

menerima perkhidmatan kesihatan yang tidak bias. Persekitaran yang baik

bukan sahaja merujuk kepada persekitaran fizikal malahan juga merujuk

kepada budaya, pengetahuan dan sikap petugas kesihatan terhadap pengidap

HIV -positif. Pengetahuan yang kurang memuaskan dan sikap negatif terhadap

pengidap mV-positif telah dikenalpasti sebagai an tara penyebab

perkhidmatan yang tidak memuaskan. Kajian ini bertujuan untuk menilai para

jururawat dari segi pengetahuan mengenai HIV dan sikap mengambil berat

terhadap pengidap HIV -positif serta factor-faktor yang mempengaruhinya.

Kajian keratan rentas telah dijalankan dikalangan jururawat yang bertugas di

21 Klinik Kesihatan Ibu dan Anak yang terletak di dalam Daerah Kuching

(n= 173). Respon terhadap kaj ian adalah 93.1 % (n= 161). Maklumat untuk

kajian telah didapati melalui borang soal-selidik. Pengetahuan berkaitan HIV

diukur melalui jawapan 'ya' atau 'tidak' bagi setiap pemyataan, manakala

sikap terhadap pengidap HIV -positif diukur men~gunakan skala Likert yang

bemilai antara 1 ke 6. Hasil kajian menunjukkan bahawa peratuan jururawat

yang mempunyai pengetahuan yang baik adalah 57.1 % manakala sikap positif

terhadap pengidap HIV -positif adalah 77%. Walabagaimanapun, salah

tanggapan terhadap pengidap HIV-positifmasih dikesan. Sehubungan itu, bagi

vii

mencapai dan mengekalkan tahap pengetahuan yang tinggi dan sikap positif

jururawat terhadap pengidap HIV -positif, pembelajaran terancang dan

berterusan adalah dicadangkan disamping perbincangan mengenai senario

yang melibatkan masalah etikal bagi mendalami pennasalahan sikap terhadap

pengidap HIV -positif.

viii

sat Khidmat MaklumatAklidemik VERSITI MALAYSIA SARAWA](

TABLE OF CONTENTS

DECLARATION

DEDICATION

ACKNOWLEDGEMENTS

ABSTRACT

ABSTRAK

APPENDIX

LIST OF TABLES

LIST OF FIGURES

LIST OF ABBREVIATIONS

CHAPTER 1: INTRODUCTION AND LITERATURE REVIEW

1.1 Introduction

1.1.1. Purpose of the study

1.1.2. Background of the study population

1.1.3. Significance of the study

1.2. Literature review

1.2.1. Introduction

1.2.2. Epidemiology ofHIVIAIDS

1.2.3. Response to HIV/AIDS in Malaysia

1.2.5. HIV knowledge, attitudes related to HIV -positive

individuals, and associated factors among nurses.

1.2.6. Care as professional behaviour

1.2.7. The concept ofattitude

1.2.8. Theory ofreasoned action

11

III

IV

V

VI

Xli

XIV

XV

XVI

3

3

4

5

5

5

7

11

23

24

25

ix

1.2.9. Conceptual framework 27

1.3. Problem statement and research questions 28

1.4. Research objectives 30

1.4.1. General objective 30

1.4.2. Specific objectives 30

1.5. Research hypothesis 31

CHAPTER 2: METHODOLOGY Al'JD MATERIALS

2.1. Research design 32

2.2. Research participants 32

2.2.1. Background of participants 32

2.2.2. Sample size calculation, sampling method, inclusionand 34

exclusion criteria

2.2.3. Ethical approval 37

2.3. Materials 38

2.3.1. Part I: General information 38

2.3.2. Part II: Professional Resistance Scale (PRS) measuring 39

caring attitude

2.3.3. Part III: HIV knowledge questionnaire (HIV-KQ 45) 40

measuring HIV knowledge

2.3.4. Part IV: AIDS Attitude Scale (AAS) measuring general 41

attitude towards HIV -positive individuals

2.3.5. Pilot study 42

2.4. Study procedures 43

2.4.1 . Data collection 43

x

2.4.2. Data entry and analysis 44

2.4.2.1. Binary logistic regression analysis procedure 47

2.4.3. Flow of the study 48

CHAPTER 3: RESULTS

3.1. Introduction 49

3.2. SOcIo-demographic characteristics 49

3.3. Prevalence ofwillingness to care for HIV-positive individuals 52

among nurses as measured by Professional Resistance Scale

(PRS)

3.4. HIV knowledge among nurses as measured by HIV-KQ45 53

3.5. General attitude among nurses towards HIV -positive individuals 54

as measured by AAS

3.6. Relationship between socio-demographic factors, level of HIV 55

knowledge, general attitude towards HIV -positive individuals,

and willingness to care attitude

3.6.1. Relationship between socio-demographic factors and 55

willingness to care attitude

3.6.2. Relationship between HIV knowledge and willingness to 59

care attitude

3.7. Relationship between HIV knowledge and general attitude 60

towards HIV-positive individuals

3.8. Variables predicting willingness to care attitude 62

xi

CHAPTER 4: DISCUSSIONS

4.1. General discussions 71

4.2. Limitations of the study 76

4.3. Implications and recommendations 77

CHAPTER 5: SUMMARY AND CONCLUSION 80

REFERENCES 82

xii

APPENDIX

APPENDIX A: Approval letter from Ethics Committee 92

APPENDIX B: Permission to conduct study by Sarawak State 94

Health Department

APPENDIX C: Research participant information and 96

informed consent form

APPENDIX D: Questionnaires 104

xiii

LIST OF TABLES

Table 3.1 Socio-Demographic characteristics of the participants 50

Table 3.2 Independent t-test between age, working duration m 55

years and caring attitude

Table 3.3 Association between socio-demographic factors and 56

caring attitude

Table 3.4 Association between having relatives or friends who are 57

HIV -positive and caring attitude

Table 3.5 Association between history of exposure to HIV­ 59

positive patient, HIV training received, perception of

adequate HIV knowledge, and caring attitude

Table 3.6 Association between level of HIV knowledge and 60

caring attitude

Table 3.7 Association between general attitude and caring attitude 60

Table 3.8 Association between level of HIV knowledge and 61

general attitude towards HIV -positive individuals

Table 3.9 Simple logistic regression analysis of four predictors for 62

predicting nurses probability to be willing to care for

HIV -positive individuals(n= 161)

Table 3.10 The observed and predicted frequencies for carmg 66

attitude among nurses with cutoff of0.50

Table 3.11 Association between selected variables and caring 70

attitude among nurses (Multivariate logistic

regression analysis) (n=161)

xiv

LIST OF FIGURES

Figure 1.1: Conceptual Framework based on Theory of Reasoned 27

Action (Ajzen, 1989)

Figure 2.1. Research methodology and flow ofresearch 48

Figure 3.1 Logit graph showing linearity between avoidance 64

score and the 10git (coefficient)

Figure 3.2. Receiver operation characteristic 67

Figure 3.3. Scatter plot between predicted probability and Cook's 68

influential statistics

xv

LIST OF ABBREVIATIONS

AAS

AIDS

CDC

CN

HAART

HIV

MOH

MCH

MCHC

NS

PHN

PLHIV

PMTCT

PRS

SN

UNAIDS

WHO

X2

I

df

M

n

p

SD

AIDS Attitude Scale

Acquired Immunodeficiency Syndrome

Center for Disease Control and Prevention

Community Nurse

Highly Active Anti-Retroviral Therapy

Human Immunodeficiency Virus

Ministry of Health

Maternal and Child Health

Maternal and Child Health Clinic

Nursing Sister

Public Health Nurse

Person Living with HIV

Prevention ofMother to Child Transmission

Professional Resistance Scale

StaffNurse

Joint United Nations Program on HIV/ AIDS

World Health Organization

Chi-squared test

I value of independence I-test

degree of freedom

Mean

Sample size

probability value

Standard deviation

xvi

OR Odd ratio

xvii

1

More than two decades after the Human hnmunodeficiency Virus (HIV)/

Acquired ItTImunodeficiency Syndrome (AIDS) appeared globally, the HIV

pandemic remains one of the most serious of infectious disease challenges to

public health (Joint United Nations Program on HIV/ AIDS [UNAIDS], 2007).

As reported by UNAIDS in 2008, the number of death related to HIV was

estimated at 25 millions death worldwide (UNAIDS, 2008b). The HIV related

death was most likely due to inadequate access to HIV prevention and treatment

(UNAIDS 2007).

The percentage of newly diagnosed HIV -positive women and girls in

Malaysia has increased from barely 5% in 1996 to 20% in 2006 (UNA IDS ,

2oo8a). With more women increasingly contracting the disease, more children are

expected to be affected since mother-to-child transmission (MTCT) is the most

common and important source of HIV infection in childhood (De Cock et at.,

2000).

To prevent mother-to-child transmission (RMTCT) HIV transmission in

Malaysia, PMTCT programme was introduced by Ministry of Health Malaysia

(MOH) in1998. Since its introduction, the PMTCT programme has been able to

screen 99.5% of total antenatal mothers nationwide who utilized government

antenatal facilities. As of December 2006, more than 2.9 million mothers were

CHAPTER 1

INTRODUCTION AND LITERATURE REVIEW

1.1. Introduction

1

screened for HIV through this initiative, of which 0.02% to 0.04% were

confinned to be HIV-positive (MOH & Academy ofMedicine, 2008).

Although the HIV-positive mother will be followed up at the combined

antenatal specialist clinic, nurses are expected to continue basic maternal and

child health (MCH) services at the primary care level (MOH & Academy of

Medicine, 2008). As the front line workforce, nurses must provide service with

respect, irrespective of their ethnic origin, nature of health problem, religious

beliefs and social status (Nursing and Midwifery Board of Malaysia, MOH).

However, as HIV -positive individuals reportedly perceived insensitive attitudes

and experienced discriminatory acts by health care professionals, provision of

non-judgemental MCH services to HIV -positive mothers at the primary care level

is questionable (Foong et aI. , 2004; Foreman et al., 2003)

Snowden (1997) highlighted that "nurses are in a prime position to offer

health education to those who are HIV infected or who have AIDS and also to the

general public. In addition, nurses need to be offering informed care to their

patients and are in need themselves of information in order to support them while

they do their job." Therefore the challenges of the HIV epidemic have presented

health care professionals with the need to equip themselves not only with the

basic knowledge of aetiology and methods 0.[ transmission, but also an

understanding of the psychosocial effects on HIV -positive people (Jamieson et

al., 2000). To understand the psychosocial effects of HIV / AIDS, health care

profes Lonals not only need to develop their knowledge, they also need to

examine their attitudes towards HIV -positive people (Jamieson et al., 2000).

2

Hence, this study was designed to examine the caring attitude among

nurses (whether they are willing to care or not) towards HIV -positive people in

general because the nurses working at MCH clinics are also required to care for

the immediate community under the coverage of their assigned clinic. Apart from

the caring attitude, associated factors such as HIV knowledge, general attitude

towards HIV-positive individuals, and socio-demographics were also examined.

1.1.1. Purpose of the study

The purpose of this study was to detennine the prevalence of willing to

care attitude for HIV -positive people among nurses working at MCH clinics in

Kuching District. Apart from that, the study would like to assess presence of any

gaps in HIV knowledge and attitudes among nurses that may detennine how they

would care for HIV -positive people in the future.

1.1.2. Background of the study population

The study was conducted in Kuching District involving nurses who are

working at Maternal and Child Health Clinics (MCHC). AU the nurses from 21

MCHC located in Kuching District were included in the study. The nursing

census bowed 173 nurses were assigned to the clinics during the study period.

The nurse population in the clinic consists of community nurses and staff nurses

ofd i fferen t rank.

Of the 21 MCHC, 4 clinics are referral centres for high risk antenatal and

post-natal mothers, further management of neonates, infants and children below 7

3

years old and further management ofwomen requiring doctor's attention. These 4

clinics have an in-house medical officer to manage the problematic cases

including referral to specialist attention. Other clinics are manned by registered

nurses (staffnurses) and community nurses (CN).

The registered nurses rank from ordinary staff nurse (SN) as the lowest

position, to Public Health Nurse (PHN), a SN with public health post-basic

certificate, to Nursing Sister (NS) as the nursing manager. The community nurses

rank from ordinary community nurse to senior community nurse.

Nurses at MCHC are expected to perfonn routine antenatal screenmg

(including HIV -screening) for newly registered antenatal mothers. By policy, all

nurses at MCHC are supposed to receive HIV training to prepare them for pre­

and post-HIV screening counselling. The Sexually Transmitted Disease and

HIV/AIDS Unit ofSarawak Health Department organises 2 HIV training sessions

each year which cover the southern zone (Kuching, Kota Samarahan, Betong, Sri

Arnan, Sarikei, Sibu, Kapit, and Mukah) and the northern zone (Bintulu, Miri, and

Limbang). The Sarawak Health Department expects that these nurses should be

able to show adequate HIV knowledge and positive attitude towards HIV.

1.1.3. Significance of the study

Despite having a National Strategic Plan for HIV/AIDS, the impact of

HIV interventions and training in Malaysia is largely unknown since the HIV

prevention programs, be it in the past or at present, have no proper data,

monitoring and evaluation framework (UNAIDS, 2008a).

4

Pusat Khidmat Maklumat Akademik U1\1VERSm MALAYSIA SARAWAK

Therefore, the findings from this study are expected to provide baseline

infonnation on any gaps in HIV -related knowledge and attitudes towards HN-

positive individuals among nurses. The findings on willingness to care for HIV-

positive person could be useful in assisting the public health managers and nurse

managers to develop appropriate intervention plans for practicing nurses.

1.2. Literature review

1.2.1. Introduction

This section provides an overview of the HIV/AIDS situation, the

response to HIV/AIDS in Malaysia, basic HIV knowledge, concept of attitude,

nurses' attitude related to care for HIV-positive person, nurses' HIV knowledge

and general attitude towards HIV -positive person, and other associated factors.

1.2.2. Epidemiology of HIV/AIDS

The 2008 report on the global AIDS epidemic by UNAIDS stated that "on

a global scale, the HIV epidemic has stabilized, although with unacceptably high

levels of new HIV infections and AIDS deaths". Globally, there were an

estimated 33.4 million people living with HIV by. the end of 2008 with half of

them (15.7 million) being women (UNAIDS & WHO, 2009). While the

percentage of HIV -positive people has been stabilized since 2000, the overaH

number of HIV-positive people has steadily increased as new infections occur

each year and as the availability of HIV treatments extend their life (UNAIDS,

2oo8b).

5

The number of HIV -positive people in 2007 for Asia was estimated at 5.0

million (4.1 million - 6.2 million), including the 380, 000 (200, 000 - 650, 000)

people who were newly diagnosed that year (UNAIDS, 2008b). In the Asian

region, South-East Asia has the highest national HIV infection levels while there

are disparities in epidemic trends among and within the countries themselves

(UNAIDS, 2008b).

The epidemics in Cambodia, Myanmar and Thailand all show declines in

HN prevalence, with national HIV prevalence in Cambodia falling from 2% in

1998 to an estimated 0.9% in 2006. However, epidemics in Indonesia (especially

in its Papua province), Pakistan, and Vietnam are growing rapidly. As the

estimated number of HIV -positive people more than doubled between 2000 and

2005 in Vietnam, populous countries such as Bangladesh and China reported a

steady increase of new HIV infections, although at a much slower pace

(UNAIDS, 2008b).

As for Malaysia, after more than 20 years into the HIV epidemic, the

country has recorded a total of76,389 HIV-positive people as of December 2006.

Most of the reported infections occur among young heterosexual males, between

the ages of20-39 years . Seventy five percent (75%) of the cumulative HIV cases

were reported among injecting drug users. As HIV prevalence continues to be less

than 1 % but ranging from 3% to 20% among the most at-risk populations such as

sex workers and drug users, the World Health Organisation (WHO) continues to

classify Malaysia as having a 'concentrated' H!IV epidemic (UNAIDS, 2008a).

6