Assessment of the attitude of public health workers in Calabar, Cross River State of Nigeria towards people living with HIV/AIDs using the aids attitude scale

Aniekan Etokidem *, Sidney Oparah **, Udeme Asibong ***, Wilfred Ndifon*, Emmanuel Nsan*

*Department of Community Medicine, University of Calabar,  Calabar, Nigeria
** Department of Internal Medicine, University of Calabar, Calabar,
*** Department of Family Medicine, University of Calabar, Calabar, Nigeria

ABSTRACT
Context
According to the UNAIDS, Nigeria has the second heaviest burden of HIV/AIDS in Africa, with 3,459,363 people now living with the condition. Cross River State currently has HIV prevalence of 7.1%, almost double the national prevalence of 4.1%. One of the greatest challenges militating against HIV/AIDS control is stigma and discrimination. When exhibited by health care providers, stigma and discrimination can deter people living with HIV/AIDS from utilising HIV/AIDS care and services.
Objective
To assess the attitude of healthcare providers towards people living with HIV/AIDS.
Materials and methods: This was a descriptive cross-sectional study among 194 public health workers in Calabar, Cross River State of Nigeria, using a semi-structured questionnaire with a 15- point AIDS Attitude Scale.  Data collected from the study were analyzed using SPSS Software.
Results: Majority of respondents, 58.8%, agreed that despite all they know concerning how HIV is transmitted, they are still afraid of contacting it while 61.4% indicated that HIV/AIDS has made their jobs a high risk occupation. Nearly 83% of respondents indicated that they don't find it hard to be sympathetic to HIV/AIDS patients and 66% indicated that they would not feel resentful if AIDS patients accounted for a significant part of their caseload.
Conclusion: There was evidence of stigmatizing and discriminatory attitude among the respondents that need to be addressed. There is need for further attitudinal orientation and re-orientation and health education of health-workers so as to remove any vestiges of stigmatizing attitude and ensure quality health care for PLWHAs.

Keywords: HIV/AIDS, attitude, public health, health workers, stigmatization, discrimination, Nigeria.

Running title: Assessment of attitude towards people living with HIV/AIDS.

INTRODUCTION
Nigeria made its first HIV diagnosis in 1986 in the blood sample of a 13 year-old sexually-active girl. 1 According to the HIV sentinel survey conducted among ante-natal clinic attendees in 1991, the HIV prevalence was 1.8%. Subsequent surveys showed gradual increase in HIV prevalence to 3.8% in 1993, 4.5% in 1996, 5.4% in 1999 and 5.8 percent in 2001. Thereafter, there was a decline to 5.0 % in 2003 and further to 4.4 % in 2005.  This decline was not sustained as there was a rise in prevalence to 4.6 percent in 2008 followed by another decline to 4.1 % in 2010 .2 The National HIV/AIDS and Reproductive Health Survey (NARHS) conducted in 2012 recorded a national prevalence of 3.4%.3  Despite this decline, there is still cause for concern considering Nigeria's rapid population growth.
In 2003, Cross River State recorded the highest HIV prevalence (12.0%) in Nigeria. 1According to the 2010 HIV prevalence survey report, the state occupies the 9th position in the ranking of states (and the Federal Capital Territory) according to their HIV prevalence. Cross River State's prevalence of 7.1% is far above the national prevalence of 4.1%.2 Among the possible explanations for the state's past and present HIV prevalence is its contiguity with Benue State which borders the state in the North and which has, for many consecutive years, had the highest HIV prevalence in Nigeria.  Akwa Ibom State, another contiguous state (created out of Cross River State in 1987), shares socio-cultural, economic and political ties with Cross River State and had the second highest HIV prevalence in the country for many consecutive years. Another plausible explanation is poverty. HIV/AIDS is described as a disease of poverty. Poverty has been identified as the cause of some of the sexual risk-taking behavior that predisposes women to HIV transmission. Cross River State is one of the 9 states in Nigeria's Niger Delta region. According to the United Nations Development Program (UNDP), Niger Delta Report, ''poverty has become a way of life'' for the people of the Niger Delta .4
One of the greatest challenges militating against HIV/AIDS control is stigma and discrimination. Stigma and discrimination are displayed by all categories of community members. When exhibited by health care providers, stigma and discrimination can deter people living with HIV/AIDS from accessing and utilising HIV/AIDS care and services. Stigma and discrimination are suffered at home, in the workplace, in places of worship, in business relationships and even in public institutions like schools. Fear of contracting the infection, due to gaps in knowledge of its transmission, causes people, including health care providers, to have negative attitude towards PLWHAs.

A study among health care providers in Ibadan, Nigeria found that 43% of the health workers indicated that they usually reacted negatively on coming in contact with HIV/AIDS patients. 5 The study also found that 52% of the respondents expressed willingness to work in the same office with PLWHA, while only 30% would assist with the delivery of a pregnant woman with HIV/AIDS.5 A similar study in Sokoto, Nigeria, found that at least 50% of health care providers studied exhibited discriminatory practices towards patients with HIV/AIDS. The study further found that these health care providers would insist on knowing the HIV sero-status of patients before attending to them and would also disclose the HIV status of patients to other health workers and patients. 6 A study among nursing students found that in response to the question:  “When you saw an HIV/ AIDS patient for the first time, what was your reaction?”, 21.3% indicated that they were shocked, 52.0% indicated that they felt empathy for the patient, 22.3% indicated that they feared infection and 4.0% indicated that they blamed the patient .7
In Ondo State, Nigeria, a related study found that 48.8% of healthcare providers at a tertiary health center exhibited poor practices towards HIV-positive patients while 31.8% had poor attitude. The study also found that 37.7% gave varying degrees of poor responses regarding how to prevent discrimination against people living with HIV/AIDS .8

In a related study in South Africa, it was found that 25% of nurses had a negative attitude towards caring for people living with HIV/AIDS .9  Majority (66.6%) of health care providers studied in Malaysia  had negative attitudes and about 20% held extremely negative attitudes towards people living with HIV/AIDS . 10  Another study in South Africa found that patients were sometimes tested for HIV before surgery without informed consent due to fear of being infected and there was some gossiping about patients' HIV status by health care workers, thereby compromising patient confidentiality .11
A related study among health care providers in Ethiopia found mean stigma scores (as the percentages of maximum scale scores) of 37.4 % for unethical treatment of people living with HIV, 34.4 % for discomfort around them and 31.1% for unofficial disclosure. The study also found that health care providers tested and disclosed test results without consent, designated HIV clients and unnecessarily referred them to other healthcare institutions.12
Aim of the study
To assess the attitude of public health workers in Cross River State of Nigeria towards people living with HIV/AIDS.

Materials and methods
Study setting
Cross River State is located in Nigeria's Niger Delta Region. The Niger Delta region presently bears the brunt of Nigeria's HIV/AIDS burden. Cross River State is contiguous with Benue and Akwa Ibom States which have consistently had the highest and second highest HIV prevalence, respectively, in Nigeria for many consecutive years. There are a lot of socio-cultural, economic and political interactions between Cross River State and these two contiguous states.

Study design
This was a descriptive cross-sectional survey.
Study population and sampling methodology.
The study subjects were public health workers selected using convenience sampling method.
Sample size: The sample size for the study was 194. The sample size was calculated using the Leslie Kish formula for single proportion.
n = z2pq/d2
Where:
n= minimum sample size
z=standard normal deviate, estimated at 1.96 at 95% confidence level.
p= proportion of the desired attribute.
q= 1-p
d= the acceptable sampling error
An earlier study found that 87% of health care providers had positive attitude towards the treatment of PLWHAs.6 Thus, the proportion with the desired positive attitude was taken as 0.87. Provision was also made for 10% non-response.
Data collection and analysis
Data were collected using a semi-structured self-administered questionnaire. The questionnaire sought to obtain information on respondents' socio-demographic variables. The questionnaire also contained a 15-point AIDS attitude scale. The AIDS attitude scale was developed and further validated by Froman et al.13 It was first formulated to ascertain the attitude of health professionals towards HIV/AIDS. 13 The scale has three sub-sections. The first, the contagion sub-scale, deals with fear of contacting the infection from clients with HIV/AIDS. The second section, the professional resistance sub-scale, deals with unwillingness to perform professional duties on patients with HIV/AIDS. The third section, the negative emotions sub-scale, deals with empathy and sympathy towards people living with HIV/AIDS. The instrument was used to collect information regarding the respondents' attitude towards people living with HIV/AIDS. The data obtained were analyzed using SPSS software version 20. Frequencies and percentages were calculated.

Ethical Issue: The study was done in accordance with the Declaration of Helsinki. No harm was done to the participants, their autonomy and confidentiality was ensured and informed consent was obtained.

Results
Socio-demographic variables
As shown in Table 1, seventy (36.1%) respondents were males while 124 (63.9%) were females. The mean age of respondents was 40.8+8.8 years. Nurses made up 56 (28.9%) of respondents, 23 (11.9%) were medical doctors, 10.3% were Pharmacists/Pharmacy technicians, 14.9% were Medical Laboratory Scientists/Laboratory technicians,  10.3% were Community Health Officers while Community Health Extension Workers constituted 19.6%.  Majority of respondents, 135 (69.6%) were married while 20.6% were never married. One hundred and seventy-two (88.7%) respondents were Christians while one (0.5%) was a Muslim.
Table 2 shows agreement or disagreement with items on the AIDS attitude scale. It is divided into three sub-sections.

Contagion sub-scale: Majority of respondents, 119 (61.4%) agreed that HIV/AIDS has made their jobs a high risk occupation while 73 (37.6%) disagreed and 1% were undecided. Majority of respondents, 58.8%, agreed that despite all they know concerning how HIV is transmitted, they are still afraid of contacting it while only 36.1% disagreed and 5.1% were undecided.  Regarding allowing their children to go to the same school with a child with HIV/AIDS, 81.5% of respondents indicated that they were well disposed to it while 9.2% indicated that they would not allow and 9.3% were undecided. Fifteen (7.7%) respondents indicated that even following strict infection control measures, it is likely that they would become infected with HIV, if they were working with AIDS patients over a long period of time.
Professional resistance sub-scale: One hundred and sixty-six (85.6%) of the respondents disagreed with the subscale item that they would rather work with a better class of people than AIDS patients while only 17 (8.7%) agreed. Regarding the item: ''I would prefer to refer persons with AIDS to my professional colleagues'', majority of respondents, 153 (78.9%) disagreed while only 16.5% agreed and 4.6% were undecided.  With respect to the item: ''Given a choice, I would prefer not to work with AIDS patients'', 162 (83.5%) disagreed while 13.4% agreed. In response to the item: ''I would consider changing my professional specialty/position if it became necessary to work with AIDS patients'', 177 (91.2%) respondents disagreed while 4.7% agreed that they would.
Negative emotions sub-scale: Majority of respondents, 160 (82.9%) disagreed with the sub-scale item that they sometimes find it hard to be sympathetic to AIDS patients while 13.5% agreed and 3.6% were undecided. One hundred and twenty-eight (66%) respondents disagreed with the sub-scale item that they would feel resentful if AIDS patients account for a significant part of their caseload. Majority of respondents, 160 (82.5%) agreed that they often have tender, concerned feelings for people with AIDS.

Discussion
In this study, 58.8% of respondents agreed that despite all they know about how HIV is transmitted, they were still afraid of contacting it through caring for people with HIV/AIDS. That over half of the respondents had this kind of feeling is worrisome because it could influence the care given to HIV/AIDS patients. This proportion is by far higher than the 26.9% who indicated that after caring for HIV/AIDS patients, they became worried that they might get HIV in a study among nurses in a rural hospital in South Africa. 9 The same study found that 52.7% of respondents felt their work situation had become worse since the onset of  HIV/AIDS. 9 This is comparable to the finding that 61.4 % of respondents in this study indicated that HIV/AIDS has made their jobs a high risk occupation.

A study on stigmatization found that fear of contracting HIV from patients was one of the reasons why health care providers stigmatized and discriminated against PLWHAs in South Sudan .14 A similar study identified fear of occupational exposure to HIV as a determinant of stigma against PLWHAs by nurses. 15 In Bangladesh, it was found that 47.9% of health care providers studied indicated that people with HIV/AIDS should not be allowed to mix freely with other people. 16 If the populace embraces this kind of attitude, it would lead to violation of freedom of movement as well as freedom of association of PLWHAs. This can easily happen through the peer influence of health care providers on their colleagues, family members and friends who are not health care providers.
Interestingly, despite the high proportion of respondents, 61.4%, who agreed that HIV/AIDS has made their occupation a high risk one, 89.2% disagreed that following strict infection control measures, it is likely that they would become infected with HIV, if they were working with AIDS patients over a long period of time. This is good for the state's HIV/AIDS control program as this proportion of health care providers with positive attitude might be good advocates of unreserved care for patients.

A study among health workers in Lagos State, Nigeria, found that 55.9% of respondents indicated that PLWHAs were responsible for contracting HIV/AIDS while 35.4% opined that PLWHAs deserve the punishment for their sexual deeds. The study also found that with regards to willingness to work in the same office with a PLWHA, only 52.8% of the health workers interviewed responded in the affirmative. 17 In contrast, this study found that on the professional resistance sub-scale, in response to the item: ''I would rather work with a better class of people than AIDS patients'', 85.6% of respondents disagreed while only 8.7% agreed. Similarly, in response to the subscale item: ''I would prefer to refer persons with AIDS to my professional colleagues'', as much as 78.9% of respondents disagreed while only 16.5% agreed. The attitude of the respondents regarding the other items on the professional resistance sub-scale all showed that the health care providers had a better attitude towards PLWHAs. For instance, in response to the item: ''I would consider changing my professional specialty/position if it became necessary to work with AIDS patients'', 91.2% disagreed while in response to the item: ''It is best to train a few specialists who would be responsible for the treatment of AIDS patients'', 63.9% disagreed. A similar positive attitude was displayed by the healthcare providers when 73.7% of them disagreed in response to the item: ''I don't want those at higher risk for AIDS such as IV drug users and homosexuals, as patients''. In a similar study among nursing students in Turkey, it was found that 67% of respondents showed positive attitude towards treatment of patients who are at higher risk for HIV/AIDS such as intravenous drug users and homosexuals. In the same study, 77% of respondents displayed positive attitude towards AIDS patients generally. 18 However, as much as 16% of respondents in this study indicated that they don't want those at higher risk of HIV/AIDS such as IV drug users and homosexuals, as patients. This is worrisome because the anger that may emanate from having such patients may have a negative effect on the care that these health care providers give to them. Treating PLWHAs with anger can have a deleterious effect on both the patient and the health care provider. For the patient, an angry healthcare provider may mistakenly give the wrong dose of medication, which may be over-dosage or under-dosage. The angry health care provider can even administer the wrong medicine to the patient or administer either the right or the wrong medicine through the wrong route. The timing of the dosing may also be missed if the healthcare provider attends to the patient with anger. On the part of the healthcare provider, the tension arising from such anger may lead to needle stick injury, with the risk of contracting HIV or other blood-borne infectious agents. The healthcare providers' family may also suffer from transferred aggression as a consequence of what may have transpired between the provider and the patient in the hospital setting. That some of the respondents, (16%),  would not want those at high risk of HIV/AIDS such as  homosexuals and injecting drug users as patients, may be due to the fact that majority of respondents belong to either of the two major religions in the country, Christianity and Islam, both of which preach against homosexuality.

Conclusion
The response of the public health workers like feeling resentful towards PLWHAs and the fact that most of them felt that despite what they know about how HIV is transmitted, they were still afraid of contacting it, may fuel negative, discriminatory and stigmatizing attitude. There is need for further attitudinal orientation and re-orientation and health education so as to remove any vestiges of stigmatizing attitude and ensure quality health care for PLWHAs. There is need to familiarize the health care providers with the Cross River State HIV/AIDS anti-stigmatization law.

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