Cultural Adaptation of a Survey to Assess Medical
Providers’ Knowledge of and Attitudes towards HIV/
AIDS in Albania
Shane D. Morrison1*, Vania Rashidi2, Vilson H. Banushi3, Namrata J. Barbhaiya2, Valbona H. Gashi3,
Clea Sarnquist1, Yvonne Maldonado1*, Arjan Harxhi3
1Department of Pediatrics, Stanford University School of Medicine, Stanford, California, United States of America, 2Stanford University School of Medicine, Stanford,
California, United States of America, 3Department of Infectious Diseases, University of Tirana Faculty of Medicine, Tirana, Albania
Though the HIV/AIDS epidemic in Southeastern Europe is one of low reported prevalence, numerous studies have described
the pervasiveness of medical providers’ lack of knowledge of HIV/AIDS in the Balkans. This study sought to culturally adapt
an instrument to assess medical providers’ knowledge of and attitudes towards HIV/AIDS in Albania. Cultural adaptation
was completed through development of a survey from previously validated instruments, translation of the survey into
Albanian, blinded back translation, expert committee review of the draft instrument, focus group pre-testing with
community- and University Hospital Center of Tirana-based physicians and nurses, and test-retest reliability testing. Blinded
back translation of the instrument supported the initial translation with slight changes to the idiomatic and conceptual
equivalences. Focus group pre-testing generally supported the instrument, yet some experiential and idiomatic changes
were implemented. Based on unweighted kappa and/or prevalence adjusted bias adjusted kappa (PABAK), 20 of the 43
questions were deemed statistically significant at kappa and/or PABAK $0.5, while 12 others did not cross zero on the 95%
confidence interval for kappa, indicating their probable significance. Subsequently, an instrument to assess medical
providers’ knowledge of and attitudes toward HIV/AIDS for an Albanian population was developed which can be expanded
within Albania and potentially to other countries within the Balkans, which have an Albanian-speaking population.
Citation: Morrison SD, Rashidi V, Banushi VH, Barbhaiya NJ, Gashi VH, et al. (2013) Cultural Adaptation of a Survey to Assess Medical Providers’ Knowledge of and
Attitudes owards HIV/AIDS in Albania. PLoS ONE 8(3): e59816. doi:10.1371/journal.pone.0059816t
Editor: Sten H. Vermund, Vanderbilt University, United States of America
Received November 23, 2012; Accepted February 19, 2013; Published March 27, 2013
Copyright: ? 2013 Morrison et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: Funding for this study was provided by the Center for East Europe and Eurasia Studies at Stanford University Summer Research Fellowship, Medical
Scholars Grant from the Infectious Diseases Society of America, and the Stanford University Goodrich Traveling Medical Scholars grant to Shane D. Morrison. The
funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing Interests: The authors have declared that no competing interests exist.
* E-mail: email@example.com (SDM); firstname.lastname@example.org (YM)
Albania is a country in Southeastern Europe that has thus far
managed to circumvent the growing HIV/AIDS epidemic in
Eastern Europe [1–9]. The number of Ministry of Health
(MoH) reported cases of HIV in Albania remains under 400 in
a country of 3.1 million [10–13]. However, recent studies
suggest that the local epidemic may have a prevalence of up to
150-fold the current estimates while risky behavioral practices
are pervasive amongst many of the at-risk groups and the
estimated emigration is 27% [10,12,14–19]. Moreover, current
data indicate that barriers to attaining HIV-medical care in
Albania are high, especially related to stigma, and one of the
most frequent patient-reported barriers was medical providers’
lack of knowledge of HIV/AIDS .
Introduction of antiretroviral therapy (ART) and preventative
interventions have proved effective around the globe, yet their
proper functioning relies on the ability of the healthcare and
public health sectors to implement them. Medical professionals’
knowledge of and attitudes towards HIV/AIDS have a substantial
impact on the usefulness of these interventions. Low levels of
knowledge about HIV/AIDS (including signs, symptoms, trans-
missibility, etc.) and discriminatory behavior against people living
with HIV/AIDS stymies the goals of prevention and treatment
regimens; such an atmosphere fosters the likelihood of increased
transmission of HIV and decreased adherence to ART [21–28].
Understanding medical professionals’ knowledge of and attitudes
towards HIV/AIDS is vital to the development of an effective
approach to HIV/AIDS within a country. A number of studies
have looked at physician knowledge of and attitudes towards
HIV/AIDS [25,27,29–35]. Indeed, recent studies in Central and
Eastern Europe, especially in the Balkans, have demonstrated that
amongst healthcare workers knowledge of HIV/AIDS is low and
discrimination is high [31,32,34,35].
Valid and reliable instruments on medical professionals’
knowledge of and attitudes towards HIV/AIDS in the developing
world have been constructed [27,33]. However, implementation
within a new country requires cultural adaptation of the previously
validated measure. A number of different studies have proposed
methods for cultural adaptation of self-reported measures [36–39].
The adaptation consists of a five-step process, 1) Translation of the
instrument to the language of the population to be measured, 2)
Back translation of the instrument into it original language to
check for accuracy, 3) Review of the instrument by a committee of
professionals who can critically evaluate the survey, 4) Pre-testing
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the instrument, and 5) Determination of reliability. Translators
that are bilingual in both languages should complete the initial
translation. A 2–3-person team should complete the back-
translation of the instrument into its initial written language to
make sure that none of the information was misinterpreted in the
translation. Committee review composed of the team that will
implement the measure serves as the final reviewer. The
instrument should be checked for semantic, idiomatic, experien-
tial, and conceptual equivalence between the versions. Pre-testing
can be approached in a number of ways including a probe
technique or focus group pre-testing. Revisions to the instrument
should be reviewed carefully before implementation. Lastly, the
reliability of the instrument can be measured by having a small
group of the study population complete the instrument on multiple
occasions and compare the results through statistical approaches
Based on the rising epidemic of HIV/AIDS in Eastern Europe,
the pervasive risky behavioral practices–including low condom
use amongst the general population and high rates of needle
sharing amongst intravenous drug users–of the predominately
younger Albanian population, and preliminary studies in Albania
indicating a patient-reported lack of medical professionals’
knowledge of HIV/AIDS, the development of a measure to
assess medical professionals’ knowledge of and attitudes towards
HIV/AIDS is warranted [10,12]. Therefore, this study aimed to
culturally adapt an instrument that can be used to assess
providers’ knowledge of and attitudes towards HIV/AIDS in
Albania and potentially expanded to other Albanian speaking
populations in the Balkans. Medical professionals with an
adequate knowledge of HIV can help prevent of the spread of
HIV within and outside of Albania and well as ensure those who
are infected receive appropriate care.
Approval for the study was granted from the Stanford
University Institutional Review Board and the Albanian Ethical
Committee. Informed written consent was obtained from each
participant prior to enrolling in the study.
The instrument was developed in conjunction with both the
Stanford University School of Medicine and the University
Hospital Center of Tirana (UHCT) HIV/AIDS Ambulatory
Clinic. The survey addresses the knowledge of and attitudes
towards HIV/AIDS. Each of the questions was adapted from
previous major studies in the developing world, including the
Albanian Behavioral and Biological Surveillance Study Report,
the Physician for Human Rights (PHR) Discriminatory Survey,
and the Vietnamese Physician Knowledge of HIV/AIDS survey
[16,27,33]. Each of these measures has been validated in the
developing world, but a cultural adaptation was necessitated prior
to use in Albania.
The survey has three main portions, 1) demographics, 2)
knowledge of HIV/AIDS, and 3) attitudes/discrimination towards
HIV/AIDS. The demographics section is brief and inquires about
the participant’s age, gender, profession (including years of
experience and estimated number of patients with HIV/AIDS
under direct care), and religion. This section will mainly be used to
inform future analysis. This section of the survey was adapted from
the Albanian Behavioral and Biological Surveillance survey and
the PHR survey [16,27]. The questions were kept in the same
relative order as they were in previous studies. The next section
focuses on knowledge of HIV/AIDS. Participants are prompted
with initial basic knowledge questions on HIV presentation,
transmissibility, and prevention of HIV/AIDS. This section of the
survey was adapted from the Vietnam and PHR studies [27,33].
The questions were kept in the same relative order as they were in
previous studies. The last and largest section of the measure
addresses attitudes/discrimination towards HIV/AIDS. This
section uses a multi-faceted approach by exploring physician
practices, informed consent of patients, physician education on
HIV/AIDS, and personal/third-party discrimination against
patient with HIV/AIDS. It also elicits perceptions of the HIV
prevalence in Albania from medical providers. The PHR survey
was the sole informant on this section and the relative order was
A bilingual postdoctoral fellow translated the survey into
Albanian. The translator had experience in the medical field, so
every attempt to keep the content as close to the original meaning
as possible was maintained while incorporating idiomatic changes.
Back translation was done by clinic-chosen translators, who
verified the accuracy of the translation. The expert committee
review (with bilingual Infectious Diseases specialists and psychol-
ogists at UHCT) before pre-testing produced the ‘‘semi-final’’
survey. Pre-testing and reliability testing were used to inform the
final version of the survey (Figure 1).
Focus groups were used for the initial pre-testing of the
instrument. Three focus groups were conducted with UHCT-
based physicians, UHCT-based nurses, or community-based
physicians. The inclusion criteria for the focus groups were: 1)
being a current practicing medical provider in Albania with
greater than 3 years of experience in their respected field, and 2)
have had a current patient population that exceeds 10 patients.
Providers were not required to have treated an HIV-positive
patient to be in this study. Even without having treated HIV-
positive patients, providers can still offer information regarding
their knowledge about HIV/AIDS or discrimination of HIV-
positive patients that they have witnessed. Providers were excluded
if they were not licensed within Albania.
Participants were recruited through departmental or clinic visits.
The focus groups consisted of the following participants: 1)
UHCT-based physicians – one rheumatologist, two allergy
specialists, one anesthesiologist, and eight infectious diseases
physicians; 2) UHCT-based nurses – five infectious diseases
nurses, one rheumatology nurse, and two intensive care nurses;
and 3) community-based physicians – one gastroenterologist, one
infectious diseases physician, two family physicians, one neurolo-
gist, and one pulmonologist.
The on-site psychologist was trained on the fundamentals of
focus group conduction, including the engagement of all
participants, the directing of questions back to the topic at-hand,
avoidance of leading responses, and flexibility in guiding the
Written informed consent was obtained prior to the initiation of
the focus groups. The survey instrument was then completed by
each of the participants. Focus groups explored initial perception
of the survey, including material, wording, and length of the
instrument, followed by an examination of individual questions.
The focus groups were conducted until no new information was
brought forth. The focus group were conducted in Albanian and
lasted from 1.5–2 hours. The groups were audiotaped for review at
a later date.
The on-site psychologist and an on-site physician at the UHCT
reviewed audiotapes and participant comments. Transcripts of the
Albanian Medical Providers’ Knowledge of HIV/AIDS
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participant comments were made in Albanian and English.
Information garnered from audiotape review was used to inform
the production of the final instrument.
Test – Retest Reliability Testing
Twenty-six providers – twelve nurses (2 from community-
based clinics), nine UHCT-based physicians, and five commu-
nity-based physicians – were given the revised survey twice
within a one-week period. The responses from each of the
participants were compared based on Cohen’s kappa. Partici-
pants that were included in the focus group pre-testing were
excluded from participation in the test-retest reliability testing.
Sample size calculation for the test-retest reliability testing was
determined based on the null hypothesis of kappa=0.0. With a
proportion of positive ratings ranging from 0.1–0.9 and an 80%
power to detect statistical significance at kappa=0.50, 25
participants were needed for the study .
Data was entered electronically and cleaned. Twenty-seven
percent of the data was reentered to check for errors: three errors
were found, yet these errors were not related to the data to be used
for reliability testing.
All data was analyzed with SAS 9.1.3. In determining the test-
retest reliability of the measure, unweighted Cohen’s kappa was
calculated for each question in the knowledge and discrimination
sections of the instrument –43 questions in total . The
responses to the questions are categorical and thus no weighting
was used–categorical responses that were used were ‘‘Yes/Agree,’’
‘‘No/Don’t Agree,’’ ‘‘Don’t Know,’’ and ‘‘No Answer.’’ The data
is presented with 95% confidence intervals and the standards for
strength agreement of kappa: #0=poor, 0.01–0.2=slight, 0.21–
0.4=fair, 0.41–0.6=moderate, 0.61–0.8=substantial, and 0.81–
1=almost perfect . Kappa values under 0.50 are not
considered statistically significant at P#0.05 . Prevalence
adjusted bias adjusted kappa (PABAK) is reported for questions
that were influenced by prevalence or bias [44,45].
Figure 1. Steps of cultural adaptation of a measure to assess medical providers’ knowledge of and attitudes towards HIV/AIDS in
Albanian Medical Providers’ Knowledge of HIV/AIDS
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Blinded back translation of the survey from Albanian to English
following its initial translation showed minimal errors in semantic
and idiomatic parameters of the instrument. The survey had to be
updated regarding some Albanian idiomatic and conceptual
parameters, including ‘‘healthcare institution,’’ ‘‘institutional
regulations,’’ ‘‘informed consent,’’ and ‘‘prescribe.’’ The bilingual
committee of infectious disease physicians and psychologists made
these changes before focus groups were undertaken. Experiential
equivalence was maintained by keeping the instrument in the
relative order as in their original instruments.
Three focus groups were conducted with 12 UHCT-based
physicians, 8 UHCT-based nurses, and 6 community-based
physicians. For the specialist breakdown of each focus group refer
to the methods section. After completion of the survey and consent
form, and discussion of the instrument in the focus group setting,
the vast majority of the participants agreed that the survey was
applicable to their constituency.
Some of the focus group participants had concerns with the
length of the survey (.100 questions) and font size (9.5 size font
used for paper conservation)–indicating possible experiential
concerns. Groups generally felt that there were only 4–5 questions
that they had trouble understanding. After focus group transcript
review, the committee updated these accordingly. The following
are quotes that illustrate the main concerns within the focus
‘‘The survey was long and I was tired by the time I finished.’’ – UHCT-
‘‘Most questions were clear, but I had to read the questions more than once
sometimes. If we paid close attention to the questions they were
understandable.’’ – UHCT-based physician.
‘‘The percentages were difficult for us to give because we do not have the
statistical information about what is going on in Albania. Other centers do
this.’’ – Community-based physician.
However, the majority of the responses expressed genuine
interest and support of the instrument. The following are direct
quotes supporting the instrument:
‘‘The survey was not too long, it was sufficient/long enough. It is feasible to
complete it in a reasonable amount of time.’’ – UHCT-based physician.
‘‘The questionnaire should be extended to other fields in medicine.’’ –
‘‘It is very clear, I think, and medical students could understand it too.’’ –
‘‘It was a valuable survey and I think that this survey should be utilized
more within the healthcare centers. Maybe more information about HIV would
be beneficial for healthcare providers.’’ – UHCT-based nurse.
After the completion of the focus groups, some changes were
made to the survey. Some of the main updates included the
insertion of a heading at the beginning of the survey that stated
that the survey is not a test and approximate answers are sufficient
to give, and another statement before questions about patient
statistics reminding participants that approximate answers are
expected. Clarifications related to what is meant by ‘‘types of
HIV’’ and ‘‘institutional protocols’’ were updated before reliability
testing was begun. Thus, idiomatic and experiential updates were
required before proceeding with reliability testing.
Test-retest Reliability Testing
Forty-three questions were tested in test-retest reliability testing;
however, the entire instrument was completed by each participant
at both stages of this testing. The questions fell into three
categories: twelve questions for knowledge of HIV/AIDS, ten
questions for discrimination against patients with HIV/AIDS, and
twenty-one questions on the care and treatment of patients with
HIV/AIDS. Seven of the twelve questions in the knowledge
section were determined to be statistically reliable at kappa or
PABAK $0.5 (Table 1): five based on PABAK and two based on
unweighted kappa. There were also three questions that do not
cross zero in the 95% CI in unweighted kappa. Six of the ten
questions in the discrimination section were deemed statistically
reliable at kappa or PABAK $0.5 (Table 1): all six based on
PABAK (one was also significant in unweighted kappa). There
were also four questions that were close to PABAK $0.5. Seven of
the twenty-one questions in the care and treatment of patients with
HIV were deemed statistically reliable at kappa or PABAK $0.5
(Table 1): all seven based on PABAK (one was also significant in
unweighted kappa). Five questions also do not cross zero in the
95% CI in unweighted kappa.
The survey instrument that was developed in this study was
made available to the UHCT HIV/AIDS Ambulatory Clinic. As
this is currently the only clinic providing HIV-specialty care in
Albania and there is a strong collaboration with the Institute of
Public Health in Albania, it is the best point for further
implementation and dissemination. The instrument is made
available to anyone interested in receiving a copy by contacting
the authors. Future discussions with the MoH are planned for
Cultural adaptation of instruments to future areas of imple-
mentation is vital to assure collection of accurate and meaningful
data [36–38]. Direct translation of an instrument, without proper
cultural adaptation, may not efficiently portray the correct
semantic, idiomatic, experiential, and conceptual equivalences
across instruments–leaving garnered data unfit for proper inter-
pretation. Proceeding through cultural adaptation steps ensures
that the measurement tool is culturally suited for the target
population. This study went through the steps of cultural
adaptation of an instrument to measure medical professionals’
knowledge of and attitudes towards HIV/AIDS in Albania. The
process of cultural adaptation used in this study is seen in Figure 1.
In-depth translation of the instrument allowed incorporation of
Albanian idiomatic and semantic changes while maintaining its
conceptual and experiential English equivalences. The quality of
this initial translation was supported by the blinded back
translation, which suggested only slight changes to the idiomatic
equivalences in the Albanian version in order to maintain
accuracy with the initial instrument. Synthesis of the ‘‘semi-final’’
instrument based on review from the expert committee of bilingual
physicians and psychologists incorporated only minimal changes
to the idiomatic and semantic equivalences of the instrument–
mainly related to technical medical terminology.
Focus group pre-testing of the semi-final instrument was met
with support and acceptance of the instrument. The main
suggestions voiced by participants were related to the length and
formatting of the instrument. These comments implied that there
might have been the need to change in the experiential
equivalence of the instrument; however, the majority of partici-
pants declared that the instrument was the proper length for its
assessment (see results section). Based on both of these inputs, it
was recommended by the committee that there be no changes to
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Table 1. Kappa and PABAK for questions from the test-retest reliability testing.
Kappa 95% CIPABAK Kappa Agreement
Knowledge of HIV/AIDS
1. People can protect themselves from infection with HIV by having good
2. People can protect themselves from infection with HIV by having one
uninfected faithful sexual partner
0.527 0.168–0.8870.615 Substantial
3. People can protect themselves from infection with HIV by not sharing
a toilet seat with a person who has HIV
0.462 0.100–0.824 0.429Moderate
4. People can protect themselves from infection with HIV by using a
condom correctly every time they have sex
20.144– 20.004 0.615Substantial
5. People can protect themselves from infection with HIV by not sharing
a meal with a person who had HIV
6. People can protect themselves from infection with HIV by avoiding
7. People can protect themselves from infection with HIV by not sharing
needles and syringes that have previously been used
20.095–0.0150.846 Almost Perfect
8. Can a pregnant woman infected with HIV transmit the virus to her
0.529 0.211–0.8470.539 Moderate
9. Can a woman with HIV transmit the virus to her newborn child through
0.506 0.024–0.9890.769 Substantial
10. Are there more than two types of HIV?0.462 0.147–0.7760.462 Moderate
11. Is HIV one example of a sexually transmitted disease?1.000N/A 1.00 Perfect
12. Do sexually transmitted diseases increase the probability of being
infected with HIV?
20.000– 20.000 0.923 Almost Prefect
Discrimination Against Patients with HIV/AIDS
13. Have you observed others refusing to care for an HIV/AIDS patient?0.616 0.221–1.0000.769 Substantial
14. Have you refused to care for an HIV/AIDS patient?0.490 0.471–0.5090.923 Almost Perfect
15. Have you observed others refuse an HIV/AIDS patient admission to a
16. Have you refused an HIV/AIDS patient admission to a hospital? 0.220
17. Have you observed others give confidential information to a family
18. Have you given confidential information to a family member?0.139
19. Have you observed others give confidential information to a
20. Have you given confidential information to a non-family member?0.3160.015–0.6160.846Almost Prefect
21. Have you observed others verbally mistreat an HIV/AIDS patient?0.171
22. Have you verbally mistreated an HIV/AIDS patient?0.3160.015–0.6160.846Almost Prefect
Care and Treatment of Patients with HIV/AIDS
23. A person’s HIV status can be determined by his/her appearance0.005
24. Treating someone with HIV/AIDS is a waste of resources
20.000– 20.0000.923Almost Perfect
25. A person with HIV/AIDS cannot be treated effectively in this facility 0.2660.022–0.5100.077Fair
26. Medications to treat opportunistic infections may prolong an HIV
positive patient’s life
20.000– 20.0000.846Almost Perfect
27. It is OK to test someone for HIV without their knowledge0.299 0.004–0.5950.231 Fair
28. Many of those who contract HIV/AIDS behave immorally and deserve
to have the disease
29. If someone has HIV/AIDS his employer/coworkers should be told even
is she/he does not give permission
30. A health professional with HIV/AIDS should not be working in any area
of the health profession that requires patient contact
31. People with HIV/AIDS should not be employed in the health field0.050
32. All prospective workers should submit to mandatory HIV/AIDS testing0.319 0.039–0.5990.154Fair
33. All prospective health care workers should submit to mandatory
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the experiential equivalence of the instrument. Still, some of the
participants were confused with the role of the survey, the
questions asking for approximations, and some technical terms. To
adjust for these issues, the committee, based partially on
participant suggestion, made changes to the experiential and
idiomatic equivalences. First, a line, in bold and all capitals, was
added after the introduction indicating that the survey is not a test
and is solely interested in participant’s opinions/approximations.
Secondly, a line preceding questions exploring patient prevalence
approximations was added to let participant know that approx-
imations are expected as answers. Since some participants felt
confused on the approximation/statistical questions (see results
section), these lines were added to inform participants of the
purpose of the questions. Finally, some Albanian idiomatic
changes to ‘‘institutional protocols’’ and ‘‘types of HIV’’ were
updated prior to reliability testing of the instrument.
Test-retest reliability testing was undertaken to determine the
reliability of the instrument. Participants were given the test twice
over a one-week period and the reliabilities of 43 questions were
determined. Based on this testing, 20 questions were deemed
statistically reliable at kappa and/or PABAK $0.5 while 12
questions did not cross zero in the 95% CI for unweighted kappa.
In total, 32 of the questions could be deemed reliable for further
studies (Table 1). Of the total questions that could be reliable in
future studies, ten were from the knowledge section (83% of this
section), ten were from the discrimination section (100% of this
section), and twelve were from the care and treatment section
(57% of this section). The vast majority of questions that were not
deemed as being reliable were derived from the care and
treatment section; this section explores participant opinions of
treatment procedures, integration of HIV-positive patients into
society, release of confidential material, and other parameters
related to the social stigmas of HIV/AIDS. Since this instrument is
designed to evolve as participant perceptions evolve in relation to
HIV/AIDS, the non-reliability of parts of this section are
acceptable as participant perception may have changed within a
week, thus it was decided not to alter this section for future studies.
The main limitations that exist in this study are related to the
use of only a single translator of the original instrument, the small
sample size for test-retest reliability testing, and the un-reliability of
certain answers within the instrument. Sometimes in cultural
adaptation, more than one translator commissioned to produce a
translation; these translations are then synthesized into a common
instrument. However, the use of a single initial translator in this
study did not jeopardize the instrument, for the back translation,
which suggested only minimal changes, and the pre-testing both
supported the accuracy and comprehensibility of the instrument.
The smaller sample size for the test-retest reliability testing only
allowed us to determine statistical significance at unweighted
kappa and/or PABAK $0.5. This high kappa value may limit the
actual number of questions that are considered statistically
significant. However, when assessing questions using those not
crossing zero on 95% CIs, we were able to show that most
questions are reliable. Still, some questions were unreliable;
however, as the instrument is meant to evolve with participant
perception changes, the unreliable questions were deemed
acceptable for use in the study.
In light of the limitations of this study, a final instrument was
produced that is ready to be used in a national (Albania) or
regional context (Kosovo and Former Yugoslavian Republic
(FYR) of Macedonia). This instrument is poised to assess medical
providers’ knowledge of and attitudes towards HIV/AIDS within
a culturally Albanian region; though there are cultural differences
amongst Albanian populations throughout the Balkans, this
instrument, constructed in standard Albanian, provides a com-
prehensible initial survey for further development outside of
Albania proper, if needed. As previous studies have identified low
levels of knowledge of HIV/AIDS within medical providers within
the Balkans, this instrument can be used to assess the providers
within culturally Albanian populations and as a starting point for
future related studies in this region.
Table 1. Cont.
Kappa95% CI PABAK Kappa Agreement
34. People with HIV/AIDS should be on a separate ward in a hospital
0.364 0.132–0.5870.231 Fair
35. Staff and health care professionals should be told when a patient
has HIV/AIDS so they can protect themselves
0.5740.252–0.895 0.692 Substantial
36. The charts/beds of HIV/AIDS patients should be marked so that clinic/
hospital workers know the patient’s status
0.368 0.063–0.672 0.308Fair
37. The treatment of opportunistic infections in HIV/AIDS patients wastes
38. The quality of life of HIV/AIDS patients can be improved with
39. I can refuse to treat an HIV/AIDS patient to protect myself and family 0.4220.086–0.758 0.615Substantial
40. There are circumstances that are appropriate to test a patient for
HIV/AIDS without asking the patient for permission/without telling the
0.273 0.059–0.487 0.077 Fair
41. There are circumstances where it is appropriate to reveal a persons
HIV status to others without the patients knowledge/permission
42. There are circumstances where it is appropriate NOT to reveal a
person’s HIV status to him or her
43. Relatives and sexual partners of HIV/AIDS patients should be notified
for the patients HIV/AIDS status even without his/her consent
Albanian Medical Providers’ Knowledge of HIV/AIDS
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Gathering and synthesizing information related to HIV
prevalence, treatment, medical providers’ education, and policy/
public health interventions throughout the world has proved
difficult, as evidenced by lack of data in many of the large
databases constructed by leading international health organiza-
tions [2,4,9]. One reason for this is due to lack of cultural
adaptation of assessment instruments to the population, leading to
bias or inadequate data [37,38]. By culturally adapting this
instrument to the Albanian population, inadequacy of data
gathering will be circumvented in future implementation of this
instrument, something past studies lacked, making this a more
rigorous and novel approach. Moreover, with numerous patients,
who were receiving care at UCHT HIV/AIDS Ambulatory
Clinic, reporting a barrier to them receiving HIV/AIDS specialty
care was due to medical provider lack of knowledge of HIV/
AIDS, future implementation of this instrument on a national level
may have striking public health and policy responses . This
could include the restructuring of the medical education to put
more emphasis on HIV/AIDS, especially as the epidemic is still on
the rise in Eastern Europe. With greater understanding of HIV/
AIDS by medical providers, more patients could effectively reach
the care and treatment they need, thus quelling the potential
spread of the epidemic. As the Albanian population is continuing
to grow along with the current high rates of emigration, a
healthcare sector effectively prepared to address HIV/AIDS
within Albania could have enormous consequences on reducing
the spread of the epidemic; something we hope to assess with this
new and validated instrument.
The authors thank Taulant Bacaj of Stanford University School of
Medicine for translation of the instrument into Albanian; Dritan Agalliu of
Stanford University School of Medicine for review of the initial translation;
Cynthia Castro of the Stanford Prevention Center for feedback on the
development of the project; Pranvera Kulla of the UHCT HIV/AIDS
Ambulatory Clinic for help with consenting and recruiting participants for
the study; and the staff at the UHCT Infectious Diseases Clinic and the
Stanford University School of Medicine Department of Pediatric Infectious
Diseases for making this project possible.
Conceived and designed the experiments: SDM CS YM AH. Performed
the experiments: SDM VHB VHG AH. Analyzed the data: SDM VR NB
CS VHB AH. Contributed reagents/materials/analysis tools: SDM CS
YM AH. Wrote the paper: SDM VR NB AH.
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