Sameen Siddiqi ( Health Services Academy, Pakistan Institute of Medical Sciences, Islamabad. )
Salma A.Majeed ( Epidemiology Unit, Pakistan Institute of Medical Sciences, Islamabad. )
Mohsin Saeed Khan ( Health Services Academy, Pakistan Institute of Medical Sciences, Islamabad. )
A knowledge, attitude and practice survey of acquired Immune Deficiency Syndrome (AIDS) was conducted among 805 paramedics at a tertiary care hospital in Islamabad in mid 1993. The mean age of the study population was 29.0±7.2 years and 59% were males. Almost 25% individuals either had no or upto primary level education. Initial response of 10% subjects was not having heard of AIDS and 70% thought their knowledge was sketchy, while 43% could not mention any cause for the disease. Almost 50% did not know that HIV infection could be asymptomatic.
With respect to attitudes about AIDS, 30% subjects thought that changing life style shall have no effect on avoiding AIDS, 50% were of the view that at present AIDS did not pose a significant threat to them and 4% individuals however, admitted to having risk of contracting the disease.
There existed significant gaps in the knowledge and attitudes of paramedical staff about AIDS and correlated with the level of education of the staff. These deficiencies need to be addressed through developing health education packages in local languages, targeted especially towards paramedical staff (JPMA 45:200,1995).
It is over 13 years since AIDS was first recognized and the rapid global spread of the disease has caught governments, communities and health care personnel unprepared. The response AIDS has evoked world-wide varied from the compassionate and energetic provision of care, support and education to restrictive and coercive displays of prejudice and fear. AiDS has notjust entered this country, itis now implanted as an indigenous disease and a part of our hospital practice. The pmjected figures for the existing number of HI V-AIDS cases in Pakistan is anywhere between 20,000-50,0001. A sympathetic as well as enlightened response from our health care workers at all levels in the care and management of HIV (Human Immunodeficiency Virus) infected as well as AIDS patients is essential. The health care worker not only should be sympathetic in caring for the AIDS patient, be well informed about the diverse aspects of the disease and be well versed in protecting herself/himself from contracting the disease. Numerous knowledge, attitude, belief and practice (KABP) studies have been carried out on health workers in different parts of the world2-4. The objective of this study was to assess the KABP related to AIDS of health care workers, particularly the paramedical and allied staff, in a tertiary care hospital in Islamabad. Such a study would identify existing weaknesses in the KABP of paramedical staff regarding AIDS. In addition, it may be useful in preparing a health education package on HIV/AIDS targeted at the group of health care personnel working in hospitals.
Subjects and Methods
A survey was conducted in mid-1993, to assess the KABP of paramedical personnel working at the Pakistan Institute of Medical Sciences, Islamabad. This study conducted on paramedical and allied personnel, included student and staff nurses, technicians working in various departments of the hospitals, nursing assistants as well as some of the auxiliary staff. A sample size of 800 individuals was considered sufficient. Hospital staff were categorized as those with "high" educational background, when they had completed secondary or higher level of education and "low" education background, if they had only done primary or were illiterate. A questionnaire was prepared to assess knowledge, attitude, behaviour and practice of the study subjects on AIDS, translated into Urdu, field tested and then modified according to the feedback from the field test. Two female community health nurses and two male paramedical employees of the hospital were recruited and trained to administer the questionnaire. The administering of questionnaire by the interviewers was continuously supervised by a physician. Data from the questionnaires was then entered on a microcomputer using EPIINFO version 5.0 and then analyzed. Only where necessary, aX2 test was performed for companng groups.
A total of 805 individuals wete assessed.Of these 59% were males with a mean age of29±7.2 years. The age range for the selected samplewas fmm 17-59 years (Figure).
Categories of individuals interviewed included 54% paramedics, 33% nurses and 13% auxiliary staff. Analysis of subjects by religion revealed 25% to be Christians. predominantly nurses. 75% Muslims and less than 1% from other religions including Hindus. The educational characteristics of the study population were also assessed, 23% of employees had either none or primary education, 44% had secondaiy and 33% had acquired higher education. The initial response on whether individuals had heani about the disease was 10% in the negative. A good 70% considered their knowledge on AIDS to be sketchy. When inquired as to the principal causes of AIDS 43% could not mention any (Table I).
Thirty one percent identified it only as a sexually transmitted disease, whereas 14% mentioned sex, blood transfusion and syringes. 22% suggested a viral etiology and of these 13% named the HIV virus. No one suggested likely transmission of disease from the mother to fetus. A detailed evaluation of the knowledge status of the study subjects is given in Table II.
Almost 50% of hospital staff either did not know or said that HIV infection cannot be asymptomatic. When asked specifically, 90% of study subjects seemed to have adequate infonnation regarding modes of transmission of the disease through sex. parenterally and from mother to fetus. There were, however, major gaps in their knowledge as to how the disease could not be transmitted, 64% of the subjects either did not know or thought that HIV infection could spread by insect bites. Similarly 40% subjects were of the view that AIDS could be transmitted by wearing clothes of an AIDS patient and another 12% had no clue about the mode of transmission. Finally 34% of the hospital staff presumed that HIV infection can be transmitted by touching an AIDS patient, or had no knowledge about it. Knowledge about AIDS was closely associated with the level of education. For instance, whereas 95% of the paramedicals with secondary or higher level of education expressed that AIDS is transmitted through sharing syringes, only 80% hospital employees with under primary or no educational background gave the same answer (p<0.001). Similarly when asked about the potential of disease transmission through commercial sex workers or by touching AIDS patients, there was significant effect of the level of education on the knowledge status (Table III).
Attitudes and behaviours of the hospital employees regarding AIDS and HIV disease were also assessed. Sixty three percent discussed the subject of AIDS freely among friends, only 14% discussed such issue within the family. When questioned as to whether AIDS can be avoided by changing life styles, more than 30% responded negatively. Over 50% individuals thought that at present AIDS either poses no threat oronly a minorone. When asked about dangers of the disease to our community in coming years, 26% still recognized either no ora minor threat. Interestingly 4% of the hospital staff conceded that they have a serious risk of contracting the disease, 13% admitted to having some risk and 11% did not know about it.
Paramedical staff alongwith doctors am major health care pmviders in our hospitals. Reluctance to care for AIDS patients has been observed world-wide wherever AIDS patients are seen. Indeed, hospital staff need to have comprehensive instructions about AIDS, the many manifestations of both the disease itself and the pandemic. In this study 10% of hospital paramedical staff on initial interrogation expressed not having heard about AIDS. This is unacceptable, while for the other 90%who had heard of AIDS, there existed significant gaps in their knowledge and attitude about AIDS which should be filled. This gap was significantly more in individuals with low level of education working in hospital environment. A similar study5 identified predictors of nursing and medical students’ levels of HI V-AIDS knowledge and their resistance to working with AIDS patients. The results revealed that lack of clinical experience with AIDS patients and anti-homosexual attitudes were significantly associated with low levels of knowledge. In our study within the group of staff with “higher educational status”, the sub-group of nurses had majorshortcomings intheirattitudes about AIDS patients.
Nurses in our hospitals are responsible for administering the major portion of direct health care to AIDS patients. Unless the pre-service curriculum of nurses as well as other paramedicals adequately covers the subject of AIDS and HIV infection, including psychosocial, ethical and legal issues, their knowledge level shall remain poor and attitudes apathetic. A survey undertaken in New Zealand6 examined nurses’ attitudes to matters relating to management of patients with AIDS and the prevention of HIV infection showed strong support for current AIDS related public health measures. The nurses had a high level of knowledge and awareness about AIDS and believed that AIDS patient should be treated no differently than other disease sufferers. As shown in this study, 70% of the respondents thought that their knowledge on AIDS was sketchy and 43% failed to suggest a cause for the disease. These are extremely high proportions for any hospital staff and more so in a teaching hospital. Moreover, the hospital staff had major misconceptions about ways through which AIDS could not be transmitted. This should be addressed through developing suitable health education packages in local languages, targeted towards paramedical staff. Another rationale for providing health education to the hospital staff is that 17% expressed some risk of contracting the disease themselves and another 11% had no knowledge about it. One can assume that gaps in KAP of medical personnel working inothersimilarand lowergrade hospitals areperhaps even worse. There is thus a pressing need to launch a determined and courageous health educationcampaignfor our hospital staff not only in the teaching hospitals but also at district and lower level health care institutions. Although this study does not assess the KAP of physicians, there is evidence thatphysicians working in hospitals as well as those in general practice not only in this country but other countries as well7,8, require to improve their skills and attitudes vastly towards HI V-AIDS patients. One limitation that we discovered was that interviews could have been more open and candid particularly discussing attitudes and behaviours than were kept in this study. This has been taken care of in our subsequent KAP studies that are at present being conducted in some of the HIV-AIDS high risk groups. Finally, HIV infection and AIDS is a reality in this country and is going to get evermore common. Sensitizing the hospital staff to the various aspects of disease through an active health education programme is crucial if we are to succeed in the endeavor to successfully control the disease. An equally important fact is that this study indirectly reflects the KAP of the general population about the catastrophic nature of this disease. Something for the medical community and health planners to think about!
1. PC-I 1994-97, National AIDS Prevention and Control Programme, Islamabad, Ministry of Health, 1994.
2. Gauch, R. R., Feeney. K. B. and Brown. J. W. Fear of AIDS and attrition among medical technologists. Am. J. Public Health, 1990;80:1264-5.
3. Henry, K C.. Campbell, S. and Willenbring, K. A cross-sectional analysis of variables impacting on AIDS related knowledge, attitudes and behaviors among employees of a Minnesota teaching hospital. AIDS Educ. Prev., 1990;2:36-47.
4. Passannante, M. R., French, J. and Louria, D. B. How much do health care providers know about AIDS? Am. J. Prey. Med., 1993,9:6-14.
5. Ficarrotto, T. J., Grade. M., Bliwise, N. et al. Predictors of medical and nursing students’ levels of HIV-AIDS knowledge and their resistance to working with AIDS patients. Acad. Med., 1990;65:470-1.
6. Willds, D. J. A survey of nurses attitudes to AIDS related issues. N. Z. Nurs. Forum, 1990;18:7-9.
7. Bailey. L. G.. Johnson, B.C., Starkey, P. L. et al. Health care workers\\\' knowledge and attitude conceming AIDS. J.Miss. State. Med. Assoc., 1989;30:355-9.
8. Naji, S. A., Russel, I. T. Foy, C. J. et al. HIV infection and Scottish general practice: knowledge and attitudes. J. R. CoIl. Gen. Pract.. 1989;39:284-8.