Indian J Med Res 122, September 2005, pp 258-264

HIV-related knowledge, attitudes & risk perception amongst nurses, doctors & other healthcare workers in rural India
Michelle Kermode, Wendy Holmes*, Biangtung Langkham+, Mathew Santhosh Thomas+ & Sandy Gifford** Australian International Health Institute, School of Population Health, University of Melbourne, * Burnet Institute & ** Refugee Health Research Centre, LaTrobe University, Victoria, Melbourne, Australia & +Emmanuel Hospital Association, New Delhi, India
Received September 14, 2004

Background & objective: People with HIV in India frequently encounter discrimination while seeking and receiving healthcare services. The knowledge and attitudes of healthcare workers (HCWs) influences the willingness and ability of people with HIV to access care, and the quality of the care they receive. Previous studies of HIV-related knowledge and attitudes amongst Indian HCWs have been conducted primarily in large urban hospitals. The objective of this study was to asses HIV-related knowledge, attitudes and risk perception among a group of rural north Indian HCWs, and to identify predictors of willingness to provide care for patients with HIV infection. Methods : A cross-sectional survey of 266 HCWs (78% female) from seven rural north Indian health settings was undertaken in late 2002. A self-administered written questionnaire was made available in English and Hindi, and the response rate was 87 per cent. Information was gathered regarding demographic details (age, sex, duration of employment, job category); HIV-related knowledge and attitudes; risk perception; and previous experience caring for HIV-positive patients. Logistic regression modelling was undertaken to identify factors associated with willingness to care for patients with HIV. Results: The HCWs in this study generally had a positive attitude to caring for people with HIV. However, this was tempered by substantial concerns about providing care, and the risk of occupational infection with HIV was perceived by most HCWs to be high. After controlling for confounding, HCWs willingness to provide care for patients with HIV was strongly associated with having previously cared for patients with HIV (P = 0.001). Knowledge of HIV transmission and perception of risk were not associated with willingness to provide care. Interpretation & conclusion : The findings of this study showed a general willingness of HCWs to provide care for patients with HIV, tempered by concerns regarding provision of such care. Strategies to address HCWs concerns are likely to ameliorate the discrimination experienced by people with HIV when accessing healthcare services. These include the development of programmes to promote occupational safety of HCWs and involving people with HIV in awareness training of HCWs. Key words Attitudes - health personnel - HIV - India - knowledge

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Ever since HIV was first identified in India among sex workers in Chennai during 19861, HIV infections have been reported in all states and territories. The estimated prevalence of HIV infection among people aged 15-49 yr is approaching 1 per cent and at least four million people are infected, making it the country with the second largest number of HIV positive people in the world2-4. The pattern of the HIV epidemic in India varies from State to State. HIV prevalence is highest in the south (Maharashtra, Karnataka, Tamil Nadu and Andhra Pradesh) where sexual transmission is dominant and in the north-east (Manipur and Nagaland) where injecting drug use is the most common route of infection. In these regions, HIV prevalence in the general population has exceeded 1 per cent5,6. Factors that contribute to the spread of HIV in other low-income countries such as internal migration of large groups of men (truck drivers, miners, military), civil instability, drug use, untreated sexually transmitted infections, poor literacy, gender inequality and endemic poverty, are also present in India2,4. In India, as in many other countries, people with HIV frequently encounter discrimination when seeking and receiving health care services, with serious adverse consequences for their physical and psycho-social well-being7. The knowledge and attitudes of healthcare workers (HCWs) in relation to HIV infection is an important factor influencing the willingness and ability of people with HIV to access care, and the quality of the care they receive. How HCWs perceive their own risks in relation to caring for HIV-positive patients potentially influences their willingness to provide care. There are studies assessing HIV-related knowledge and attitudes among HCWs in India 8-12, but all were conducted in large urban hospitals. The objective of the present study was to assess HIV-related knowledge, attitudes and risk perception among a group of rural north Indian HCWs, and to identify predictors of willingness to provide care for patients with HIV infection. Material & Methods A cross-sectional survey of HCWs (n=266) was conducted in seven rural north Indian health settings (hospitals with attached community health projects)

during late 2002. All of these health settings are administered by an Indian non-government organisation, which provides healthcare and other services to the rural poor, and is committed to maximising the quality of care, despite limited resources. The characteristics of the health settings are summarised in Table I. The data were collected as a component of a larger survey investigating injection safety and HCW safety, and other findings from the survey have been reported elsewhere 13,14. HCWs were asked to complete an anonymous written questionnaire. Findings from a preliminary qualitative investigation, involving a four-month period of observation and interviews with 40 HCWs in two rural north Indian health settings, substantially informed the content of the questionnaire, which was pilot tested in India and made available in English and Hindi. The Hindi version was back-translated to ensure equivalence of the items. Information was gathered regarding: demographic details (age, sex, duration of employment, job category); HIV-related knowledge and attitudes; risk perception; and previous experience caring for HIV-positive patients. Many of the questions invited the HCWs to indicate their response using a Likert scale15. All HCWs employed at the selected health settings were invited to participate in the survey. The questionnaires were distributed and collected in unmarked envelopes by one of the authors (MK) with the support of senior hospital personnel. Those who did not wish to participate were requested to return the questionnaire unanswered. The data were analysed using SPSS Version 11.5. The statistical tests used to assess the strength of association between variables included Chi-square, independent samples t-test, one-way ANOVA, simple linear regression and binary logistic regression. Ethics approval for the study was granted by the Deakin University Human Research Ethics Committee (Melbourne, Australia) and senior personnel from the collaborating Indian organisation reviewed the ethics application prior to submission in Australia. All potential respondents were clearly advised that participation in the survey was voluntary and anonymous.

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Results Demographics: Of the 307 questionnaires distributed, 87 per cent were returned completed (Table I). The response rate tended to be better in smaller health settings compared to larger ones, but all sites had a response rate >80 per cent. The average age of respondents was 30.5 yr (range 18-62 yr, SD 10.3) and the majority were female (77.9%). The average duration of employment was 9.8 yr (range 1- 38 yr, SD 9.5). Slightly more than half (52.3%) chose to complete the questionnaire in English. The majority of respondents were nurses (28.5% general nurse midwives, 14.1% auxiliary nurse midwives, and 32.7% student nurses), 12.5 were doctors, 6.1 laboratory workers, 1.1 per cent dentists and 4.9 per cent others (operating theatre and ophthalmic technicians, dental assistants, multi-purpose workers). Knowledge of HIV transmission: Participants were asked to indicate whether or not they agreed with 12 statements regarding possible routes of HIV transmission (Table II). The correct response was scored as one and the incorrect and not sure responses as zero. An overall knowledge score was calculated by summing the scores for each statement, thus the highest possible score was 12. The mean score was 9.5 (range 4-12, SD 1.71). Although participants were generally aware of the ways in which HIV can be transmitted, their knowledge of how HIV is not transmitted was often incomplete. Attitudes to caring for patients with HIV/AIDS and perception of risk : Slightly more than half of the respondents (57%, 128/223) reported that they had previously cared for an HIV-positive patient. Participants were asked to what extent they agreed or disagreed (using a five-point Likert scale ranging from strongly agree to strongly disagree) with seven statements regarding their attitudes to caring for patients with HIV and two statements about routine HIV testing of patients (Table III). Participants were asked to indicate the extent to which they agreed or disagreed with two statements about the risk of occupational HIV infection for HCWs generally and for themselves specifically (Table III). Additionally, they were asked to rate their own risk of becoming infected with HIV at work as low or high. The majority (63%) perceived their risk of

occupational infection with HIV as high. They were also asked about the risk of HIV infection following a needlestick injury with a needle contaminated with HIV-positive blood. Sixty per cent thought the risk was 100 per cent, and only 11 per cent correctly identified it as 0.3 per cent. Predictors of preferring not to care for patients with HIV : Logistic regression modelling was undertaken to identify factors associated with unwillingness to care for HIV-positive patients. The dependent variable was agreement with the statement I would prefer not to care for patients with HIV/ AIDS. Demographic variables (sex, age, language, hospital site, length of time in the job and job category), having previous experience of caring for an HIVpositive patient, HIV knowledge score and perception of personal risk were entered into the model. After controlling for confounding, unwillingness to care for patients with HIV was associated only with having never cared for someone with HIV (Odds ratio, OR 0.14; 95% CI 0.05, 0.43: P = 0.001) i.e., those who had previously cared for a patient with HIV were more willing to care. Discussion The fact that a substantial proportion of HCWs believed that HIV could be transmitted by contact with saliva, urine and faeces, mosquitoes, coughing and sneezing, and sharing plates, cups and spoons indicated that knowledge about HIV transmission was incomplete. It was also of concern that 25 per cent were unaware that HIV could be transmitted through breastfeeding and 26 per cent did not know that tattooing was a risk for HIV transmission. This indicates that HCWs in rural north India require more training regarding the ways by which HIV is and is not transmitted. It is especially important that the risk of transmission through breastfeeding is better understood, so that HIV-positive pregnant women receive appropriate and consistent advice. The majority of participants (91%) perceived HCWs as being at high risk of occupational infection. These HCWs are likely to be overestimating their risk of occupational infection with HIV, as the majority (60%) incorrectly believed that a needlestick injury with an HIV-contaminated needle was certain to result in infection. Although the overall risk of

KERMODE et al: HIV & HEALTHCARE WORKERS IN RURAL INDIA Table I. Healthcare settings that participated in the survey No. of hospital 1 2 3 4 5 6 7 Total *Hospitals were not always operating at full capacity **Hospitals with student nurses UP, Uttar Pradesh; MP, Madhya Pradesh; O & G, obstetrics & gynaecology Table II. Proportion with correct responses to statements about HIV transmission Statement Sexual intercourse can spread HIV/AIDS Sharing plates, cups and spoons can spread HIV/AIDS HIV/AIDS can be spread from an infected woman to her child during pregnancy and birth Contact with urine can spread HIV/AIDS Mosquitoes can spread HIV/AIDS HIV/AIDS can be spread from an infected woman to her child during breastfeeding Coughing and sneezing can spread HIV/AIDS Contact with faeces can spread HIV/AIDS Blood transfusion can spread HIV/AIDS Tattooing can spread HIV/AIDS HIV/AIDS can be spread when needles are shared by IDUs Contact with saliva can spread HIV/AIDS No. responded 254 259 257 254 255 253 255 254 255 246 255 252 % correct 99.6 88.4 99.2 61.4 70.6 75.1 82.7 68.9 98.4 73.6 95.7 37.7 State Uttaranchal Uttaranchal UP Jharkhand** Assam** Chattisgarh MP** Bed capacity* 35 115 40 100 70 76 100 Specialist services surgery, O & G, paediatrics, ophthalmology, community health, dental surgery, paediatrics, orthopaedics, O & G, community health surgery, O & G surgery, O & G, ophthalmology, community health surgery, O & G, orthopaedics, urology, community health surgery, O & G, community health, infectious diseases, orthopaedics, ophthalmology surgery, O & G, ophthalmology, dermatology/leprosy, community health, dental No. distributed 16 59 12 39 67 30 84 307 No. completed 16 50 12 35 54 25 74 266

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occupational infection after a needlestick injury with a needle containing HIV-infected blood is estimated to be 0.3 per cent16, individual risk is mediated by a range of factors including the prevalence of HIV in the patient population and the nature and number of exposures. It is possible that unwillingness on the part of HCWs to participate in invasive procedures on patients with HIV infection related to concerns about their own safety. These concerns could be ameliorated if Standard/Universal Precautions were more effectively implemented in these settings13 and HCWs received accurate information regarding the risk of occupational infection with HIV.

Almost all participants believed that it was necessary to take extra infection control precautions when caring for patients with HIV and 78 per cent believed that they should be nursed separately from other patients. These findings highlight a lack of understanding regarding the primary principle underlying Standard/Universal Precautions i.e ., the precautions apply universally and not selectively. When Standard/Universal Precautions are applied appropriately it is not necessary to isolate HIV-positive patients (unless they have tuberculosis or other opportunistic infections that require isolation) and identification of infected patients for the protection of patients and HCWs is not required.

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Table III. Proportion agreeing with statements related to attitudes to patients with HIV, attitudes to routine HIV testing, and perception of risk Statement Attitudes to people with HIV I feel worried about caring for people with HIV/AIDS Doctors, nurses and other HCWs should be allowed to refuse to care for people with HIV/AIDS I am willing to assist with an operation on a patient with HIV/AIDS I am willing to assist with the delivery of a baby born to a mother with HIV/AIDS I would prefer not to care for patients with HIV/AIDS It is necessary to take extra infection control precautions for patients with HIV/AIDS Patients with HIV/AIDS need to be nursed separately from other patients Attitudes to routine HIV testing All surgical patients should be routinely tested for HIV/AIDS on admission to hospital All obstetric patients should be routinely tested for HIV/AIDS on admission to hospital Risk perception Doctors, nurses and other HCWs have a high risk of catching BBVs (such as HIV/AIDS and hepatitis B) while caring for patients I worry about catching HIV/AIDS at work BBVs, Blood-borne viruses 257 254 90.6 58.2 249 246 93.2 94.7 252 250 248 247 244 251 251 77.9 15.2 71.0 82.6 23.0 97.2 78.1 No. responded % agreeing

A high proportion of HCWs (almost 95%) felt that all surgical and obstetric patients should be routinely tested for HIV infection, presumably to identify those patients requiring precautions. This finding was similar to that reported in a study of nursing students in Delhi where up to 85 per cent favoured making HIV testing compulsory for high risk groups, in-patients and health workers10. However, routine HIV testing of patients does not reduce the risk of occupational exposure17 and some newly infected patients will have a negative HIV test result even though they are both infected and infectious. The value of Standard/Universal Precautions is that they protect HCWs and patients against infection with a range of pathogens, not just HIV. Moreover, routine HIV testing is more expensive that practicing Standard/Universal Precautions18. The proportion of HCWs willing to care for HIVpositive patients in this study was consistent with that reported among nursing students in Delhi 9, and senior nurses in Calcutta 8 . Potential for discrimination against HIV-positive patients was suggested by the fact that 15 per cent believed that HCWs should be allowed to refuse care for HIV-positive patients, although this was slightly less than the 25 per cent of Delhi nursing student who agreed that health personnel should be allowed to refuse care for AIDS

patients 10 . Being prepared to provide care was strongly associated with having previous experience of caring for someone with HIV, but was not associated with knowledge about HIV transmission routes or perception of risk. An earlier Indian study also found that HCWs HIV-related knowledge and attitudes did not predict their willingness to care8. Previous studies have also identified a connection between prior contact with HIV-positive patients and a more tolerant attitude 19,20. This finding reinforces the value of including people with HIV (if they are willing to disclose their status) in HIV-awareness training of HCWs. There are some inherent limitations with such studies. When responding to questions about attitudes to patients with HIV, some HCWs might have felt the need to give responses that were socially acceptable in the context of an organisation with an explicit mission to provide care for the socially marginalised. Consequently, the proportion of HCWs preferring not to care for patients with HIV might have been underestimated. It was not possible to identify the characteristics of HCWs who failed to return the questionnaire, so potential differences between responders and non-responders could not be identified. However, the response rate (87%) was high and there

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was no reason to suspect that non-responders were substantially different from responders. The survey sample was not representative of all HCWs in rural north India, so the findings should be generalised with caution. It is probable that awareness of HIV-related issues among the HCWs participating in this survey was generally better than that of their colleagues from other north Indian health settings, as some of the survey sites have been involved in HIV prevention and care activities. This study investigated HIV-related knowledge, attitudes and risk perceptions among a group of HCWs in rural north India and found a general willingness to provide care for patients with HIV, tempered by substantial concerns regarding the provision of such care. In India, the prevalence of HIV infection is growing and HCWs are increasingly involved in a range of HIV prevention and care activities including the prevention of mother-to-child transmission, provision of antiretroviral treatment to people with HIV-related illness, and prevention of transmission through blood transfusions and unsafe injection practices. In order to minimize the discrimination experienced by people with HIV, it is important that the concerns of HCWs are addressed. These findings highlight a need for programmes that promote the occupational safety of HCWs in rural north India and the value of involving people with HIV in HIVawareness training of HCWs. Acknowledgment
Authors thank Dr Damien Jolley, Associate Professor, Monash University, Melbourne, Australia, Dr Nick Crofts, Associate Professor (University of Melbourne, Australia), Dr Vinod Shah, Emmanuel Hospital Association, New Delhi, India, the senior staff in all the hospitals where the survey was undertaken, and the healthcare workers who participated. The first author (MK) was the recipient of a Public Health Postgraduate Research scholarship from the Australian National Health and Medical Research Council (NHMRC).

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UNAIDS. Report on the global HIV/AIDS epidemic 2002. Available from: http://www.unaids.org. Accessed 17 October, 2003. World Bank. Issue Brief HIV/AIDS: South Asia Region (SAR) India. 2003. Available from: http:// www.worldbank.org.in. Accessed 17 October, 2003. National AIDS Control Organization. Combating HIV/AIDS in India, 1999-2000. New Delhi: Ministry of Health and Family Welfare, Government of India. UNICEF. South Asia: The HIV/AIDS epidemic. 2001. Kathmandu: UNICEF, Regional Office for South Asia. Asia Pacific Network of People Living with HIV/AIDS. AIDS discrimination in Asia. 2004. Available from http:// www.gnpplus.net/regions/asiapac.html. Accessed 16 June, 2004. Fusilier MR, Durlabhji S. Health care workers AIDS attitudes and willingness to provide care - India. J Health Hum Serv Adm 1997; 20 : 145-58. Datta C, Bandyopadhyay D. Knowledge and attitudes in relation to HIV/AIDS among in-service nurses of Calcutta. J Indian Med Assoc 1997; 95 : 75-7.

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Reprint requests : Dr Michelle Kermode, NHMRC Public Health Post-doctoral Fellow, Australian International Health Institute School of Population Health, University of Melbourne, Level 5/207 Bouverie Street, Victoria 3010, Australia e-mail: mkermode@unimelb.edu.au