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 Table of Contents  
Year : 2018  |  Volume : 5  |  Issue : 2  |  Page : 143-148

Sensitizing health-care workers and trainees to create a nondiscriminatory health-care environment for surgical care of HIV-Infected patients

1 Department of Orthopaedics, Christian Medical College, Vellore, Tamil Nadu, India
2 Department of Internal Medicine, Skane University Hospital, Lund, Sweden
3 Department of Anaesthesiologist and Intensive Care, Vrinnevi Hospital, Norrkoping, Sweden
4 Orthopedic Department, Lillebaelt Hospital, Kolding, Denmark
5 Emergency Department, Regional Hospital North Jutland, Bispensgade 37, 9800 Hjorring, Hjorring, Denmark

Date of Web Publication9-Apr-2018

Correspondence Address:
Deeptiman James
Department of Orthopaedics, Christian Medical College, Vellore - 632 004, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/cjhr.cjhr_98_17

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Background: Occupational risk of human immunodeficiency virus (HIV) transmission creates barriers in the surgical health care of patients with HIV infection. Poor awareness, prevalent misconceptions, and associated stigma lead to discrimination against HIV-infected patients. This study was carried out to assess effectiveness of a “HIV awareness program” (HAP) to educate and motivate health-care workers to provide equitable and ethical health care to HIV-infected patients. Methodology: An interventional study was conducted at a secondary level mission hospital in Central India from April 2014 to August 2015. Change in knowledge, awareness, and attitude following a multimedia “HAP” was analyzed with a “pre- and posttest design.” Seventy-four staffs and trainees participated in the program. Z-test and t-test were used to check the statistical significance of the data. Results: The mean pretest score was 19.31 (standard deviation [SD]: 6.0, 95% confidence interval [CI]: 17.923–20.697) and the mean posttest score was 30.84 (SD: 4.8, 95% CI: 29.714–31.966). This difference was statistically significant at the 5% level with P < 0.001. Conclusions: “HAP” was effective in changing the knowledge, awareness, and attitude of the staffs and trainees of the secondary hospital toward surgical care of HIV-infected patients.

Keywords: HIV awareness, sensitizing health-care workers, stigma in health care

How to cite this article:
James D, Ehrstedt F, Sundholm J, Harel NN, Egge S. Sensitizing health-care workers and trainees to create a nondiscriminatory health-care environment for surgical care of HIV-Infected patients. CHRISMED J Health Res 2018;5:143-8

How to cite this URL:
James D, Ehrstedt F, Sundholm J, Harel NN, Egge S. Sensitizing health-care workers and trainees to create a nondiscriminatory health-care environment for surgical care of HIV-Infected patients. CHRISMED J Health Res [serial online] 2018 [cited 2022 May 23];5:143-8. Available from: https://www.cjhr.org/text.asp?2018/5/2/143/229595

  Introduction Top

Acquired immunodeficiency syndrome (AIDS) is a major global public health concern. The AIDS pandemic has claimed 34 million lives, with 1.2 million HIV-related deaths reported in 2014 alone.[1],[2] By the end of 2014, approximately 36.9 million people were reported to be living with human immunodeficiency virus (HIV) infection worldwide. According to the National AIDS Control Organization, India has the third highest number of people living with HIV infection across the world.[3] Stigma and discrimination associated with HIV have created a barrier between health-care workers (HCWs) and patients with HIV infection.[4],[5] It is not uncommon for HCWs to have an unfavorable attitude toward HIV-positive patients, which leads to discriminative acts, such as delaying or changing a patient's treatment, minimizing contact with the patient, denying assistance to pregnant woman during delivery, and demanding additional payment for health-care services.[4],[6] A spectrum of knowledge deficit ranging from “isolation of HIV patients” to “felt need for specialized training” has been identified among HCWs.[4],[7] HCWs and trainees are at risk of exposure to HIV-infected body fluids.[8],[9] Training and awareness programs are necessary to ensure primary prevention against occupational exposure to HIV infection. The aim of this study was to assess effectiveness of a novel “HIV awareness program” (HAP) to overcome prevalent attitude toward HIV-infected patients to create a nondiscriminatory environment at a secondary hospital in rural central India.

  Methodology Top

An interventional study was conducted at a secondary level mission hospital in Central India from April 2014 to August 2015. Current literature was reviewed for discrimination against HIV-infected patients in hospitals and studies regarding willingness to care for HIV-infected patients among health-care workers. A pilot study and in-depth focus group discussions were conducted to assess prevalent discriminatory practices and attitude toward HIV-infected patients undergoing surgical care in the mission hospital. A HAP was designed as an experimental intervention. An interactive, 45 min multimedia presentation with relevant information about HIV infection, transmission, universal precautions, and protection against occupational risk of HIV transmission was administered in English and Hindi, and real case scenarios were included in the program [Figure 1]. Separate HAP sessions were conducted for medical staffs, housekeeping staffs, and trainees. HAP included eight subsections and highlighted the occupational risks of HIV infection. It encouraged adoption of universal precautions, appropriate hand hygiene protocols, and overcome discrimination against HIV-infected patients. A “one group pre- and posttest study” design was adopted to verify whether HAP changed the awareness and attitude regarding care of HIV-infected patients. A questionnaire was administered to all HCWs and trainees before and after HAP. Participation in the pre- and posttest was voluntary, and confidentiality of all participants was ensured. Data collection and data analysis were done by separate researchers to overcome ascertainment bias.
Figure 1: Bilingual human immunodeficiency virus awareness program multimedia presentation

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The questionnaire refined through a pilot study contained multiple choice questions and dichotomous questions which was administered in English and Hindi [Figure 2]a and [Figure 2]b. The questions were subdivided into eight subsections:

  • Basic facts about HIV disease load
  • Occupational risk of transmission of HIV
  • Universal precautions for protection of HCWs
  • Safe practices for handling sharps at workplace
  • Hand hygiene at workplace
  • HCW attitude toward HIV
  • Isolation and identification of HIV patients
  • Knowledge about the use of gloves.
Figure 2: (a and b) Human immunodeficiency virus awareness program assessment questionnaire

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The pretest questionnaire was administered to 122 participants. Some housekeeping staffs were unable to read or write, and some participants in the group found the program too technical. Most felt that they are happy following the protocols set down by the superiors. Hence, the housekeeping staffs (n = 16) were excluded from the analysis. Eleven nurses, two doctors, and four laboratory technicians did not participate in the posttest. Four incomplete questionnaires were excluded from the study. After these exclusions, the posttest survey sample included 74 (n) participants (8 doctors, 9 nurses, and 57 nursing trainees).

Data collection

One point was awarded for each correct answer, and 0.5 point was deducted for each incorrect answer. Questions left unanswered were marked 0. Data entry was done using Microsoft Office Excel 2010. All data were converted from categorical outcome, including binary variables, to quantifiable, numerical discrete outcome. The answers from the preintervention and the postintervention questionnaires were tabulated separately and then compared through statistical analysis. Data were categorized in two different ways. First, the data were categorized as per professional groups (five groups: doctors' section, nurses' section, 1st-year nursing trainees, 2nd-year nursing trainees, and 3rd-year nursing trainees). Then, the data were categorized based on different subsections of the questionnaire (eight subsections: facts, transmission, protection, sharps, hand hygiene, isolation, fear, and knowledge of the use of gloves).

Data analysis and statistical tools

The variables responsible for causal effect of the “HAP” were analyzed through a univariate system. Pre- and posttest arithmetic means were calculated, and standard deviation was calculated to measure the dispersion of data. Null hypothesis was formulated. The null hypothesis of no significant change in the pre- and posttest means was statistically analyzed. All data were analyzed at 5% level of significance. Since the sample sizes for professional groups were small (n< 30), t-test was used to test the hypothesis. Z-test was used for testing the hypothesis where sample sizes were >30.

  Results Top

The mean pretest score was 19.31 (standard deviation [SD] = 6.0, 95% confidence interval [CI] = 17.923–20.697), and the mean posttest score was 30.84 (SD = 4.8, 95% CI = 29.714–31.966). This difference was statistically significant at 5% level of significance with a P < 0.001. The causal relationship between HAP and change in knowledge, awareness, and attitude of the HCWs and trainees at the secondary level hospital was confirmed with this statistical assessment. The mean pretest score and mean posttest score for the doctors' section were 26.94 [SD = 5.7] and 31.37 [SD = 7.2], respectively. This difference was statistically analyzed using t-test (n = 8) and found statistically insignificant (P = 0.1970). The difference between the mean pretest score (21.94 [SD = 6.439]) and posttest score (33.66 [SD = 3.596]) for the nurses' section (n = 9) was statistically significant (P = 0.0004). The difference between the mean pretest score (14.86 [SD = 3.59]) and the mean posttest score (30.25 [SD = 3.77]) for first-year nursing trainees (n = 19) was statistically significant (P< 0.0001). The difference between the mean pretest score (17.94 [SD = 3.63]) and the mean posttest score (30.85 [SD = 4.49]) for second-year nursing trainees was statistically significant (P< 0.0001). The difference between the mean pretest (20.47 [SD = 6.08]) and the mean posttest score (30.65 [SD = 4.48]) for third-year nursing trainees (n = 19) was statistically significant (P< 0.0001) [Table 1].
Table 1: Means scores for each professional group

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The change in mean pretest (3.13 [SD1 = 1.00]) and mean posttest score (3.53 [SD2 = 0.81]) for “fact awareness” section was statistically significant (P = 0.0422). The change in mean pretest (2.41 [SD = 1.51]) and mean posttest score (3.88 [SD = 1.17]) for “transmission awareness” section was statistically significant (P = 0.0005). The change in mean pretest (5.43 [SD = 3.19]) and mean posttest score (8.23 [SD = 0.77]) in “protection awareness” section was statistically significant (P = 0.0253). However, the change in mean pretest score (1.02 [SD = 1.13]) and mean posttest score (1.41 [SD = 0.87]) for “sharps handling awareness” section was not statistically significant (P = 0.1010). The change in mean pretest (1.82 [SD = 2.30]) and mean posttest score (6.21 [SD = 1.47]) for “hand hygiene” section was statistically significant (P< 0.0001). The change in the mean pretest score (0.21 [SD = 0.72]) and mean posttest score (0.89 [SD = 0.43]) for “attitude toward isolation of HIV patient” section was statistically significant (P< 0.0001) [Table 2].
Table 2: Mean pre- and posttest scores in HAP program sub-sections

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  Discussion Top

Health-care resources are scarce in rural India with limited infrastructure and severe shortage of workforce.[10] With gradual spread of HIV epidemic from the high-risk behavior population to the general population and spread of HIV from urban centers to rural areas, the rural health-care services including rural mission health-care sector have to gear up to share the responsibility of treatment of patients with HIV/AIDS.[11],[12],[13] Unfortunately, stigma and discrimination against HIV continue to be highly prevalent among all sections of our society.[4],[14] Discrimination against HIV-infected patients in health-care centers further complicates the scenario.[4],[5],[6],[15],[16] Apprehension in handling, treating, and unfavorable attitude toward HIV-infected patients has been witnessed across all levels of HCWs and health-care trainees.[17],[18],[19],[20],[21] Rigid moralistic attitude and “blame and shame” tactics inherent in our health-care sector lead to common practice of labeling and disclosing the patients' HIV status without consent.[4],[15],[16] Studies done across the spectrum of HCWs found that inadequate knowledge and awareness regarding HIV infection and its transmission is primarily responsible for such discriminatory practice.[17],[18],[21],[22],[23],[24] Our study identified the “fear factor” and unwillingness to handle patients with HIV infection among the HCWs and trainees in the secondary level rural mission hospital. Most participants felt that HIV-infected patients must be isolated and the “HIV status” must be highlighted with signs and banners to warn the health-care workers for their protection. Some participants also felt that the patients' family must be warned.

The Medical Council of India has put in a set of codes to reinforce nondiscriminatory and ethical approach to all patients.[25] Yet, covert and overt discrimination continues. Hence, codes and laws are not enough. Health-care workers must be motivated to change their attitude and ensure justice to people infected with HIV/AIDS. An effective health education program to change the attitude of HCWs toward HIV/AIDS-infected patients is essential to overcome their apprehension as well as reinforce the concepts of ethical and equitable treatment of all patients as equal.[15],[16]

Nearly 80 percent of our respondents reported needle stick injury. The study found lack of knowledge regarding universal precautions and hand hygiene practice among HCW and trainees. Lack of awareness about postexposure prophylaxis and misconceptions about postexposure protocol were identified. HAP intervention aimed to raise the awareness regarding both primary and secondary precautions against occupational risk of HIV transmission, especially with regard to perioperative care of HIV-infected patients. Most participants were unaware of “postexposure prophylaxis” before HAP intervention. HAP raised the awareness regarding correct methods of handling and disposal of needles and other sharp medical equipments, equipped the participants with knowledge about HIV infection and universal precautions.

An experimental interventional study module was applied to assess the effectiveness of “HAP.” The results show that “HAP” caused a significant positive shift in the knowledge and awareness regarding occupational risks of HIV transmission. It also changed the attitude of health-care workers as well as trainees toward the HIV-infected patients undergoing surgery at the rural mission hospital. Significant change was observed in the idea that HIV-infected patients need not be isolated. Participants understood that HIV-infected patients can be cared for in regular environment just like all other patients and realized that segregation and public identification of HIV-infected patients should be avoided. The study showed a significant change in understanding of the importance of hand hygiene practice and universal precautions. Hand hygiene is an essential part of universal precaution, which helps health-care workers protect themselves and other patients from disease transmission.

Health-care trainees are the future of the health-care infrastructure of the country and are influenced by the existing culture in our health-care settings. The necessity to eradicate existing misconceptions and unfavorable attitude toward patients with HIV infection at the earliest stage has been identified.[19],[20],[26] Indoctrination of ethical treatment is essential to optimize future workforce in the health-care service sector. Hence, the trainees were included in the HAP study. The study showed a significant change in the knowledge, attitude, and awareness among all levels of nursing trainees at the institution.


HAP was perceived as “too technical” for housekeeping/nonclinical staffs, who found it difficult to understand. Unfortunately, all categories of health-care workers are at risk of occupational exposure to HIV during surgical care of HIV-infected patients. Hence, it is essential that all sections of health-care workers have adequate awareness and access to preventive measures regarding occupational exposure to HIV infection. A simplified version of HAP may overcome this limitation. However, the housekeeping staff follows instructions from line managers and ward nurses in this case. We hope that HAP will help the nursing staffs to incorporate measures that will minimize occupational risk of HIV transmission for the housekeeping/nonclinical staffs.

Lack of statistical significance observed in change of awareness regarding safe handling of sharps, knowledge of usage of gloves, and fear of HIV infection may be due to inadequate information or due to inadequate assessment tools. However, encouraging trends were recognized in all these categories.

  Conclusions Top

We conclude that HAP was effective in increasing the knowledge and awareness regarding occupational risk of HIV transmission among health-care workers and trainees at the secondary level mission hospital. HAP was effective in educating the participants to maintain confidentiality and avoid isolation of the HIV-infected patients undergoing surgical care. HAP encouraged and motivated staffs and students to perceive HIV-infected patients without stigma and discrimination. HAP encouraged the principles of universal precautions. HAP raised the awareness regarding postexposure prophylaxis.

We also found that HAP needs to be tailored to the audience in order to be effective. Both language and content must be compatible with the participating audience. We posit regular updates and assessment to ensure knowledge gained through the HAP program is constructively applied to improve surgical care of HIV-infected patients in the mission hospital.


We would like to thank Mr. Milind Gude (Secretary and Treasurer, Eastern Regional Board of Health Services) and all staff and students of Christian Hospital Mungeli, Chhattisgarh, India.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2]


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