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Attitudes and Stigmas
Effect of Education on Attitudes and Stigmas
Method of Education on Attitudes and Stigmas
Limitations of Evidence
Limited Integrated Literature Review on the Efficacy of HIV Education on Improving Attitudes and Reducing Stigmas for Nursing Students
Kim E. Stewart
University of Central Florida
HIV/AIDS is a very present pandemic and has claimed the lives of more than 35 million people worldwide. Persons living with HIV/AIDS (PLWHA) often require health care during the course of their disease and in an array of healthcare settings. Nurses are often the frontrunners of patient care and it is essential that care is provided without bias, stigma or poor attitudes towards the patient. Although some countries offer HIV/AIDS education to student nurses, few have mandatory and standardized HIV/AIDS education. This review includes four studies that compare the effectiveness of HIV/AIDS education on stigmas and attitudes towards PLWHA. Results of this review found that HIV education that includes contact with a person infected with HIV within the format, offers the greatest benefit in the reduction of discrimination stigmas and attitude improvement, however that the benefits of the education lack longevity. In consideration of the growing numbers of PLWHA, nursing students may benefit from generalized education to address attitudes and stigmas towards any patient, not just the PLWHA.
Keywords: attitudes, hiv/aids education, nursing students, stigmas
HIV Education and its Effect on Reducing Stigma’s and Attitudes in the Nursing Student
According to the Centers for Disease Control and Prevention (CDC) (2017), more than 36 million people live with Human Immunodeficiency Virus (HIV) around the world.
Additionally, 161,000 people have not yet been diagnosed with HIV. The CDC (2017) reports that more than 25 million people have died from Acquired Immune Deficiency Syndrome (AIDS). According to the CDC (2015), lifetime cost for a single person’s HIV treatment is more than $350,000, representing a significant global and national financial burden. In consideration of the increasing numbers of PLWHA, it is likely that nurses will provide care to a PLWHA, at some point in their careers. Since nurses play a large role in healthcare, it is essential that care they offer to the person with HIV/AIDS is offered without poor attitudes, bias or stigmas.
Avert (2017) states that more than 50% persons with HIV/AIDs have experienced some kind of discrimination, poor attitudes, abuse, and prejudice. Avert (2017) attributes present day poor attitudes and stigmas towards HIV/AIDS infected persons to be related to the public fears that emerged from the HIV epidemic during the early 1980’s. Peril related to HIV infection can include fear of contamination, death, affiliation with homosexual behavior, drug use and personal irresponsibility. Avert (2017), states that stigma and discrimination is a worldwide dilemma and is present in the healthcare arena. The consequences to HIV discrimination, includes poor patient care within the health care arena. Nurses are often at the front line in caring for those with HIV/AIDS and often function in an expanded healthcare role (Yox & Farley, 2012). According to Yox & Farley (2012), in South Africa, nurses are the front-line providers to persons with HIV, including oversight of prescribed antiretroviral treatments. In the U.S., nurses are often responsible for the development of the HIV patient care plans, direct patient care and the monitoring of patient progress and regress. When nurses exhibit stigmas and poor attitudes towards persons infected with HIV/AIDS, quality patient care is jeopardized. HIV/AIDS education to nurses can assist with reducing stigmas and improving attitudes towards persons living with HIV/AIDS. According to American Nurses Association (2013), in the United States, six states have specific HIV educational licensure requirements for nurses. American Nurses Association (2013) reports that Washington state has the highest number of required HIV related education for nurses, at seven hours each year. Florida nurses are required to have a mere one hour of HIV/AIDS education at initial licensure, Kentucky requires their nurses to have two hours at licensure renewal, Minnesota requires two contact hours per 24 months and New York requires nurses to complete a State Education Department approved infection control course every four years (American Nurses Association, 2013).
In consideration of the documented stigmas and poor attitudes towards persons infected with HIV/AIDS, the growing number of HIV infected persons as well as the important role that nurses play in care to the HIV patient, an evaluation of HIV education and its efficacy is prudent.
This synthesis will evaluate the efficacy of HIV education for nursing students to determine if it improves attitudes and reduces stigmas towards persons living with HIV/AIDS.
A search strategy was performed to identify English written works published between 2010-2017. The following databases were utilized in the search strategy: CINAHL-Plus with Full Text, Health Source Nursing/Academic Edition, MEDLINE, Cochrane Database of Systematic Reviews and PsycINFO. The search included the following key words; HIV Education, Nursing Student and Attitude and Stigmas.
Articles were included and further reviewed if they included HIV stigmas, nursing student attitudes, HIV education for nurses and quantitative studies. Articles were excluded when they indicated research of HIV prevention, HIV Gender related studies, HIV pilot programs and studies of qualitative analysis. Criteria found in Melynk & Fineout-Overholt (2015) was utilized to determine study quality and appropriate levels of evidence.
Searches of the electronic databases resulted in ninety-three articles. Of those, seventy-two articles were eliminated due to a variety of factors. The majority of elimination factors included articles primarily focused on increasing general HIV/AIDS knowledge and studies where the participants were students outside the field of nursing. Of the twenty-one remaining articles, seventeen were further eliminated due to primary focus of a pilot study, HIV/AIDS prevention, duplicate articles, studies that failed to include an education component and those who failed to report quantitative data and analysis. The Appendix summarizes the final four articles including their study design, sample/setting, major variables studied, intervention, measurement, data analysis and findings and appraisal.
Three major themes are considered as part of this integrated literature review.
Determination of the presence of stigmas, attitudes and fears towards persons with HIV/AIDS by nursing students is examined and confirmed. The effect of formal HIV/AIDS education on stigma’s and attitudes in nursing students as well as a review of the methods of education related to short and long term effects of those stigma’s and attitudes of the nursing student.
All four studies examined nursing student’s attitudes towards working with persons infected with HIV/AIDS. Three of the four studies examine the effect of formalized education on attitudes and stigmas of the nursing students and one study compares two methods of formalized education on the effects of attitudes and stigma’s, over the short and long term.
Attitudes and Stigmas
Two of the four studies utilized the AIDS Attitude Score (AAS) a questionnaire to compare attitudes and stigmas pre-and post-education. The AAS is a 15-item, 6-point Likert scale questionnaire that was developed to determine attitudes toward HIV/AIDS patients by medical and nursing students. The sub scores on the AAS include fear of contagion, professional resistance and negative emotions. Scores range from 15-90 and higher scores on the AAS indicate negative attitudes towards persons with HIV/AIDS. Two of the four articles recorded pre-and post AAS scores. The study by Neriman et al., (2012) reported pre-intervention AAS scores to average 46. The research conducted by Atav, Sendir, Darling & Acaroglu (2015), reported AAS scores to average 37 for males and 41 for female nursing students, pretest. Both studies revealed that poor attitudes from nursing students towards persons living with HIV/AIDS (PLWHA), was primarily due to fear of contagion and negative emotions toward the homosexuals and HIV/AIDS patients.
The study conducted by Shah et al., (2014) reported that that 57% of the nursing student’s participants held at least one misconception about HIV transmission and that 38% of the nursing student participants felt that persons who contracted HIV, deserved it. The Shah et al., (2014) study reported that at pre-intervention, 85% of participants intended to discriminate when dispensing medications, and 96% of the sample intended to discriminate or provide unequal or biased care, when drawing blood from the Person Living with HIV/AIDS (PLWHA). The same study reported that at pre-intervention, 51% of participants felt that PLWHA should be medically serviced in locations different than patients without HIV/AIDS.
Effect of Education on Attitudes and Stigmas
The four studies report that education to nursing students has a positive effect on attitudes and stigma toward PLWHA. The study by Shah et al., (2014) included two 1- hour classroom sessions with focus on health care associated stigma and instrumental and symbolic stigma. It is duly noted that the second one hour session included a guest speaker living with HIV/AIDS with focus on the perceived stigmas he has faced in the health care settings. Post intervention resulted in no change with intent to discriminate or unequal care when drawing blood, however the study reports a significant improvement in post intervention HIV related knowledge scores. The intervention included in the study by Neriman et al., (2012) consisted of a one 2-hour power point presentation as opposed to the two 1-hour session completed in the Shah et al., (2014) study. The results of the Neriman et al., (2012) study revealed post intervention AAS scores to be significantly improved.
Method of Education on Attitudes and Stigmas
The Yiu et al., (2010) and Shah et al., (2014) research contained educational interventions that included more than standard lecture. Both studies included interventions that encompassed actual contact with PLWHA. Results of the Yiu et al., (2010) study revealed significantly less stigmatizing attitudes in the knowledge with contact intervention group. Both the knowledge contact and knowledge only group showed significant improvements in willingness to treat PLWHA. Although the study completed by Neriman et al., (2012), reported significant improvements in attitudes and stigmas, the study utilized a lecture only intervention. The studies using both lecture and contact with PLWHA resulted in greater improvements in stigmatizing attitudes.
Limitations of Evidence
The studies utilized the identical test, pre-and post-intervention, introducing possible bias. Prejudice included linking study participation to nursing student grades and gifts such as gift cards with small monetary value. Since participants were nursing students, the possibility of the nursing student’s desire to please their instructor, is considered. Geography is also considered a limitation. Two of the four studies were held in Turkey and compared to U.S. studies, with the population of the US being three times that of Turkey. Sample size limitations were evident in three out of four of the studies. Lastly and important two out of the four studies failed to report lasting effects of HIV education at the 6 week follow up, meaning the effects of the education were not sustained over time.
Nurses are often at the front line of providing care to PLWHA. The studies reported that nursing students place stigmas and have poor attitudes towards PLWHA, which can result in less than optimal healthcare delivery.
The reported studies offer evidence to support that HIV/AIDS education improves immediate attitudes and reduces stigmas in nursing students. Pre-versus post education test scores report significant improvements in transmission misconceptions, intent to discriminate, willingness to treat, fear of contagion and blame statements. All four studies offered classroom based intervention ranging from one 50-minute lecture to one 2-hour classroom discussion. Two of the studies offered classroom discussion as well as contact with PLWHA. When comparing classroom education with classroom education paired with contact with PLWHA, the latter resulted in significantly greater improvements in pre-and posttest attitudes and stigmas. Improvements in attitudes and stigmas were not sustained at the as reported in two of the four studies meaning consideration for on-going education is warranted.
HIV/AIDS is becoming a chronic condition and persons living with HIV/AIDS are living longer and longer. According to the WHO (2017), there are more than 36.7 million people living with HIV in 2015 with 34.9 million of those being adults and 1.8 million account for children infected with HIV. In consideration of the number of HIV infected persons as well as the extended life of the HIV patient, it is likely that nurses will provide care to the HIV patient some time in their career. It is essential that nurses are educated and prepared to offer care to the HIV patient, without stigma and poor attitudes. Providing HIV education to nurses is one way to begin to improve the way nurses approach the HIV patient.
HIV education for nursing students and other medical professionals while mandatory in some states, is not for all. There is evidence as to the short-term benefit of HIV education which makes an argument that education can be beneficial to the medical professionals and to the patient with HIV. Since the results fail to prove longevity of the effectiveness of HIV education, perhaps a more suitable approach to reducing stigmas and attitudes would be to incorporate nursing student’s bias’s in all patient’s and not just the patients with HIV/AIDS. Addressing nursing student’s attitudes and stigma’s throughout their formalized education would ensure that bias was routinely addressed and discussed as it naturally presented itself during clinical rotations as well as during classroom lecture.
In light of the reviewed studies, future research should focus on ways that education incorporates avenues for nursing students to address their own prejudices and bias towards any patient and throughout their nursing education and career.
American Nurses Association (2013). States which require continuing education for rn Licensure 2013. Retrieved from: http://www.nursingworld.org/MainMenuCategories/Policy-Advocacy/State/Legislative-
Avert (2017) HIV and aids in the united states of America (USA). Avert. Retrieved from https://www.avert.org/professionals/hiv-around-world/western-central-europe-north- america/usa
Beaulieu, M., Adrien, A., Polvin, L. & Dassa, C. (2014). Stigmatizing attitudes towards people Living with hiv/aids: validation of measurement scale. BMC Public Health (14): 1246. Retrieved from: http://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-14- 1246
Centers for Disease Control and Prevention (2016) HIV/AIDS-basic statistics. Retrieved from: https://www.cdc.gov/hiv/basics/statistics.html
Centers for Disease Control and Prevention (2015). HIV coast-effectiveness. HIV/AIDS. Retrieved from https://www.cdc.gov/hiv/programresources/guidance/costeffectiveness/index.html
Melnyk, B. & Fineout-Overholt, E. (2015). Evidence based practice in nursing & healthcare (3rd ed.). Philadelphia, PA: Wolters Kluwer.
World Health Organization (WHO) (2017). HIV/AIDS. Retrieved from: http://www.who.int/hiv/en/
Yox, S. & Farley, J. (2012). The role of the nurse in hiv treatment and care. Medscape 2012. Retrieved from: http://www.medscape.com/viewarticle/768767
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