Substance Use & Misuse, 45:1007–1018
Copyright © 2010 Informa Healthcare USA, Inc.
ISSN: 1082-6084 (print); 1532-2491 (online)
Attitudes: Health Professionals
The Role of Physician and Nurse Attitudes in the
Health Care of Injecting Drug Users
LOREN BRENER,1WILLIAM VON HIPPEL,2
SUSAN KIPPAX3AND KRISTOPHER J. PREACHER4
1School of Psychology and National Centre in HIV Social Research, University
of New South Wales, Sydney, New South Wales, Australia
2School of Psychology, University of Queensland, St Lucia, QLD, Australia
3National Centre in HIV Social Research, University of New South Wales,
Sydney, New South Wales, Australia
4Department of Psychology, University of Kansas, Lawrence, Kansas, USA
In 2005, 60 health care workers were recruited through services that attract injecting
drug users (IDUs) and asked to complete attitude measures regarding IDU clients.
Mediation analyses indicated that conservative health care workers displayed more
negative attitudes toward their IDU clients because they believe that injecting drug
use is within the control of the IDU. Negative attitudes toward IDU clients, in turn,
were associated with worry about IDU clients’ behavior in the clinic and with beliefs
that IDU clients should disclose their hepatitis C status to their health care worker.
Perceptions of controllability of drug use were also associated with the belief that IDU
clients’ ailments were caused by their IDU status. The study’s limitations are noted.
injecting drug use; attitudes; perceptions of control; conservatism; health
Injecting drug users (IDUs) enter the health care system for a variety of reasons. They may
suffer poor health as a consequence of their injecting drug use, for example, via poor vein
This article is based on a doctoral dissertation submitted to the University of New South Wales
by the first author, under the supervision of the second and third authors. The first author was funded
by a post-graduate scholarship from the National Health and Medical Research Council of Australia,
ID No. 222922. Support for this research was also provided by grants from the Australian Research
Address correspondence to Loren Brener, PhD, School of Psychology and National Centre
in HIV Social Research, University of New South Wales, Sydney, NSW 2052, Australia. E-mail:
1008 Brener et al.
may also seek health care to control their drug use, e.g., through methadone maintenance
and other treatment programs. Many factors influence the quality of care that IDUs receive
in the health care system, including the available resources and their own ability to adhere
to treatment regimens (Sylvestre, Litwin, Clements, & Gourevitch, 2005). One important
factor that can influence the type of care that is provided to clients is the attitudes of health
care workers (Caplehorn, Hartel, & Irwig, 1997), but little is known about the role that staff
attitudes play in the treatment of IDUs.
Injecting drug use is a highly stigmatized behavior that evokes negative feelings and
associations (Ahern, Stuber, & Galea, 2007; Capitanio & Herek, 1999). It is particularly
stigmatizing because it is often perceived by others as under the control of the individual,
and thus the individual is blamed for their drug use and any related illnesses (cf. Crocker,
Major, & Steele, 1998). In such cases, less pity, less concern, and less helping behavior
toward members of the stigmatized population is elicited (Weiner, Perry, & Magnusson,
1988). Although it is probably impossible to know the degree to which drug use in any
single individual is caused by factors under that individual’s control, this relationship
between sympathy and perceptions of control suggests that those health care workers who
perceive drug use as under the control of the individual are likely to have more negative
attitudes toward them. Thus, the first hypothesis of the current research is that perceptions
of controllability of drug use will be associated with more negative attitudes toward IDUs.
Perceptions of controllability are themselves predictable from other attitudes, as peo-
ple who are politically and socially conservative tend to view individual’s behavior as
within their control, whereas people who are politically and socially liberal tend to at-
tribute comparatively greater control of individual actions to societal forces (Jost, Glaser,
Kruglanski, & Sulloway, 2003; Tetlock, 2002). Again, it is probably impossible to assess
whether conservatives or liberals are right or wrong here, or even whether these attributions
can be classified as right or wrong, but these relationships suggest that conservatives will
have more negative attitudes toward IDUs to the degree that they see drug use as under
the individual’s control. Thus, the second hypothesis of the current research is that conser-
vatism will be associated with more negative attitudes toward IDUs, and this relationship
between conservatism and attitudes toward IDUs will be mediated by perceptions of the
controllability of drug use.
Negative attitudes toward members of different groups are associated with a wide
variety of stereotypes, depending on the nature of the stereotyped group and the theories
that people hold about group members (Hilton & von Hippel, 1996). In the case of IDUs,
behavior, particularly in a health care context. For example, adherence rates to treatment
associated with injecting drug use that can make it more difficult for health care workers
to work with this population, for example, comorbid psychiatric diagnoses, homelessness,
a lack of stable psychosocial environment, poor adherence to scheduled appointments,
and limited emotional support (Sylvestre, 2003; Zweben, 2001). Additionally, health care
professionals report worries that are based on personal experience with IDUs, regarding
threats to safety, theft, and verbal abuse (von Hippel, Brener, & von Hippel, 2008).
To the degree that health care workers have negative attitudes toward IDUs, worries
such as these are likely to play a more important role in their interactions with IDUs. As
is the case with the other attitudinal variables discussed above, it is unclear whether such
worries are commensurate with the difficulties associated with working with IDUs, but the
point is not whether they are ill founded. Rather, the goal of the current research is to assess
Attitudes of Health Professionals in the Health Care of IDUs1009
whether these worries will themselves be predictable based on other attitudinal factors.
Thus, the third hypothesis of the current research is that negative attitudes toward IDUs
will be associated with worries about their behavior in treatment.
Negative attitudes toward IDUs are also likely to predict beliefs that drug injecting
clients should disclose the consequences of their drug use that could pose a threat to others,
such as their HCV status. There are clear medical reasons for believing that disclosure of
HCV is important, but there are also personal safety concerns that relate to such disclosure,
as HCV is communicable to health care workers exposed to blood products (Charles,
Angus, Sasadeusz, & Grayson, 2003). People who hold negative attitudes toward IDUs are
likely to believe that they are a greater risk for the transmission of such illnesses, and thus
are likely to believe that disclosure is very important in such populations. Thus, the fourth
hypothesis of the current research is that negative attitudes toward IDUs will be associated
with stronger beliefs that they should disclose their HCV status.
Lastly, it is also the case that beliefs about the controllability of drug use are likely to
predict other beliefs beyond negative attitudes. In particular, to the degree that people per-
own health problems. Thus, beliefs of controllability are likely to be associated with beliefs
that the health care problems of IDUs are caused by their injecting drug use. Again, it is
current research is simply to predict the beliefs that health care workers hold in this regard.
Nevertheless, such beliefs and attitudes are important, as they can influence various
other medical decisions. For example, debates surrounding this issue can be seen among
medical ethicists who argue about how to determine where somebody is placed on an organ
transplant waiting list. Those who are perceived to have caused their own poor health (e.g.,
via addictions) are often placed later on the waiting list than those who are perceived to be
innocent victims (Gillon, 1995; Steinberg, 2004). Thus, the fifth and final hypothesis of the
proposed research is that beliefs of controllability of injecting drug use will be associated
with beliefs that a greater proportion of the health care problems of IDUs are caused by
their injecting drug use.
In sum, we propose the following set of attitudinal relationships. First, health care
workers who are more conservative will be more likely to perceive injecting drug use as
under the individual’s control. Second, perceptions of drug use controllability will in turn
predict more negative attitudes toward IDUs. Third, perceptions of drug use controllability
will also predict stronger beliefs that the medical problems of IDUs are caused by their
injecting drug use. Fourth, negative attitudes toward IDUs will be associated with worries
and concerns about the way these clients behave in the treatment setting. Fifth, negative
attitudes toward IDUs will be associated with stronger beliefs that they should disclose
related health problems that could pose a threat to others, such as their HCV status. In
an exploratory study designed to test these possibilities, we measured these attitudes and
beliefs among a sample of health care workers who treat IDU clients. We then conducted
path analyses of the beliefs and attitudes reported by health care workers to assess whether
these constructs were associated with each other in the manner predicted above.
The sample consisted of 60 health care workers (doctors and nurses). Recruitment targeted
services that attract IDUs, such as needle and syringe programs, methadone clinics, and
1010 Brener et al.
drug user treatment facilities. Recruitment sites were concentrated around the Sydney
metropolitan area. Health care workers completed the measures on a laptop computer
individually at the treatment facility during work hours (e.g., during their lunch break), and
were given a gift voucher of $25.
Materials and Procedure
Participants completed the scales below in the following order: First, health care workers
completed a 5-item scale measuring negative attitudes and behaviors toward IDUs (e.g., “I
avoid injecting drug users whenever possible”; Cronbach’s α = .57, M = 2.14, SD = .52).
Health care workers then completed a 4-item scale measuring perceptions of controllability
of injecting drug use (e.g., “Injecting drug users are responsible for their addiction”;
Cronbach’s α = .75, M = 2.19, SD = .74). Responses to these measures were provided
on a 5-point scale ranging from strongly disagree to strongly agree. These scales were
developed for the purpose of this study and validated prior to use (Brener & von Hippel,
Health care workers then completed the 12-item revised Wilson Conservatism Scale
(Cronbach’s α = .71, M = 1.33, SD = .30), which assesses social conservatism (Hen-
ningham, 1996). Responses to this scale were provided on a 3-point scale labeled yes,
uncertain, or no. Next, health care workers completed two items that asked how much of
their IDU clients’ physical and mental health concerns are related to their injecting drug
use. Responses to these questions were provided on a 4-point scale ranging from none
to all. Because the two items were significantly correlated (r = .31, p < .02), they were
collapsed into a single indicator (M = 2.08, SD = .39).
Health care workers then completed a 4-item worry scale that assessed the types of
worries and concerns they have about the behavior of IDUs in the treatment service (e.g.,
“You worry that he/she may become violent”; Cronbach’s α = .73, M = 1.62, SD = .47).
Responses to this scale were provided on a 3-point scale labeled not a concern, a minor
concern, or a major concern. Finally, health care workers were asked whether they think
their drug injecting HCV+ clients should be encouraged to disclose their HCV+ status to
their health care workers. Responses were provided on a 4-point scale ranging from never
Table 1 outlines the characteristics of the sample. All services through which participants
were recruited were located in geographical areas in metropolitan Sydney where there is a
concentration of IDUs. Service providers in the area are therefore familiar with IDUs and
these services cater to the needs of IDU clients.
According to predictions, conservatism should predict perceptions that injecting drug use
is controllable. Perceptions of controllability, in turn, should predict perceptions that other
ailments are caused by injecting drug use and should also predict negative attitudes toward
IDUs. Finally, negative attitudes should predict worry about the behavior of IDU clients
and should also predict beliefs that IDU clients should disclose their HCV status.
We examined these predictions using path analysis models as implemented in Mplus
v. 5.0 (Muth´ en & Muth´ en, 1998–2007). Bias-corrected bootstrapped confidence intervals
are reported for all effects—for regression slopes as well as for indirect effects—because
Sample characteristics (n = 60)
Type of practice
Clients serviced by the facility
3 doctors (1 female)
M = 46.7 (41–53)
Accessed by people on methadone
1 nurses (female)
Primary health care
2 medical students (female)
M = 23.0 (20–26)
Accessed by IDUs for health care, people on
methadone, most had needle and syringe
5 doctors (2 female)
M = 45.6 (30–55)
13 nurses (9 female)
M = 44.3 (27–58)
program facility on site
1 doctor (male)
For hepatitis C treatment, liver problems
5 doctors (1 female)
M = 46.6 (30–59)
For hepatitis C treatment and liver problems
related to injecting drug use
9 nurses (female)
M = 44.2 (29–59)
Drug and alcohol
7 doctors (3 female)
M = 46.6 (42–57)
Accessed by people on methadone, people
14 nurses (10 female)
M = 49.2 (30–62)
seeking drug user treatment and people with
drug- or alcohol-related problems
1012Brener et al.
dardized regression weights. Note:∗indicates that zero is not in the 95% confidence interval.
Path model depicting relationships among modeled variables. Path coefficients are stan-
indirect effects are based on unstandardized regression weights. We used 20,000 bootstrap
resamples to obtain accurate confidence limits. Prior to the regression analyses, bivariate
correlations were computed for all the variables in the analyses (see Table 2). Path analysis
results are also reported in Table 2. Model fit was excellent [χ2(df = 5) = 1.33, p = .93;
CFI = 1.00; TLI = 1.00; RMSEA = .00, 95% CI:.00, .05; SRMR = .02].
Consistent with predictions, path analysis indicated that health care worker conser-
vatism predicted negative attitudes toward IDUs indirectly through perceptions of control-
lability of injecting drug use (indirect effect = .257, 95% CI:.077, .570; see Figure 1).
Negative attitudes toward IDUs, in turn, predicted worry about the behavior of IDU clients
(β = .291, 95% CI:.044, .501) and the belief that IDU clients should disclose their HCV
status (β = .591, 95% CI:.213, 1.005). Conservatism also indirectly predicted beliefs that
the ailments of IDUs are due to their IDU status via perceptions of controllability (indirect
effect = .153, 95% CI:.025, .416). All path coefficients and indirect effects are reported in
Table 2, along with 95% bias-corrected bootstrapped confidence intervals.
Prior research has identified both conservatism and perceptions of controllability of the
cause of a person’s stigma as related to negative attitudes toward stigmatized group mem-
bers (Herek, 2002). The results of this study extend these conclusions by suggesting that
perceptions of controllability of injecting drug use play a critical role in the formation of
negative attitudes toward IDUs among health care workers. The current data suggest that
conservative health care workers have more negative attitudes toward their IDU clients,
but only to the extent that they also see drug use as under the individual’s control. That is,
there was no longer a significant relationship between conservatism and attitudes toward
IDUs once drug use controllability was controlled in the path analyses, suggesting that
conservative health care workers are not inherently more negatively disposed toward IDUs
than liberal health care workers.
Descriptive statistics and confidence intervals for unstandardized path coefficients and indirect effects
Correlations, means, & standard
Problems due to IDU
Negative IDU attitudes
Should disclose HCV
Conservatism → Controllability
Conservatism → Problems due to IDU status
Conservatism → Negative IDU attitudes
Controllability → Problems due to IDU status
Controllability → Negative IDU attitudes
IDU attitudes → Worry
IDU attitudes → Should disclose HCV
Conservatism → Controllability → Problems
Conservatism → Controllability → IDU Attitudes
Note:∗p < .05.
1014Brener et al.
The current results also indicate that those health care workers who perceived injecting
drug use as under their clients’ control attributed more of their clients’ ailments to their
injecting drug use. Although the perception that the ailments of IDUs are related to their
injecting drug use was not significantly correlated with conservatism, the indirect effect of
conservatism (via controllability) on perceived causes of their ailments was significant. As
Shrout and Bolger (2002) have argued, because mediation tests have greater power than
bivariate tests to detect small to moderate relationships, such mediation findings should
often be considered meaningful even in the absence of a significant direct effect. Thus,
the current data suggest that more conservative health care workers might differ from their
more liberal counterparts in the types of diagnoses they make regarding their IDU clients.
and also with greater endorsement of the belief that IDUs should disclose their HCV status.
These attitudinal findings naturally raise the issue of whether these concerns have their
roots in the reality of injecting drug use. Although that question is certainly unanswerable
with regard to any particular individual, at an aggregate level it is clear that these concerns
are reflected to varying degrees in the reality of injecting drug use. Injecting drug use can
lead to vein damage, infections, gangrene, and overdose, as well as long-term damage
to a number of organs (Dunn & Laranjeira, 1999; Gossop, Griffiths, Powis, & Strang,
1992; Strang et al., 1998). The lifestyle associated with injecting drug use may also result
in violent crime or sex work to support drug acquisition (Donoghoe & Wodak, 1998).
For young injectors, drug use is linked to homelessness, school dropout, delinquency, and
& Anthony, 1990). In Australia, hepatitis C is also a major concern for IDUs. By the end of
2004 it was estimated that there were 260,000 people in Australia infected with HCV with
anincidence rateof9,700new infections ayear (NationalCentreinHIVEpidemiology and
Clinical Research, 2006). Over 90% of new infections are acquired through injecting drug
use (Australian National Council on AIDS, Hepatitis C and Related Disease [ANCAHRD]
Hepatitis C Subcommittee, 2002). Hepatitis C results in inflammation of the liver, which
can cause fibrosis (scarring of the liver) and ultimately lead to liver cancer (WHO, 2000).
For all of these reasons, IDUs pose a variety of complex challenges for health workers.
Finally, it is important to highlight the limitations of the current research. Most notably,
the study is exploratory in nature and represents a first step in understanding the inter-
relationships among the attitudes and beliefs of health care workers who work with IDU
clients. Thus, the data clearly require replication in a larger sample, ideally with a more
of treatment experiences or outcomes. Nevertheless, it seems likely that the relationships
documented in the current research will have implications for treatment. At the very least,
health care workers who believe in the importance of disclosure of HCV status are more
are caused by injecting drug use are likely to place greater emphasis on injecting drug
use in their treatment decisions. It is also possible, however, that the worries that health
care workers report regarding the behavior of their drug injecting clients will influence
their treatment decisions as well. These worries, particularly those focusing on behaviors
associated with injecting drug use, could readily provide the underlying attitudinal/belief
Attitudes of Health Professionals in the Health Care of IDUs1015
basis for differential treatment of people who inject drugs. Thus, future research should
attempt to replicate these findings in a longitudinal sample with objective indicators of
care, thereby enabling a test of the causal relationships proposed in the model and their
implications for treatment.
Declaration of Interest
The authors report no conflict of interest. The authors alone are responsible for the content
and writing of this paper.
En 2005, 60 professionnels de sant´ e travaillant dans des services qui attirent des usagers
de drogues intraveineuses (UDI) ont ´ et´ e recrut´ es et ont r´ epondu ` a des questions sur leurs
attitudes face aux clients UDI. Les analyses de m´ ediation indiquent que les professionnels
conservateurs pr´ esentent plus d’attitudes n´ egatives ` a l’´ egard des UDI car ils croient que le
fait de s’injecter est un comportement contrˆ olable par l’usager. Les attitudes n´ egatives des
professionnels envers les UDI ´ etaient quant ` a elles associ´ ees ` a des craintes concernant le
comportement des usagers dans la clinique et ` a l’id´ ee selon laquelle les usagers devraient
informer le personnel de sant´ e de leurs statut vis-` a-vis de l’h´ epatite C. Les perceptions
du caract` ere contrˆ olable de l’usage de drogue ´ etaient aussi associ´ ees ` a la croyance selon
laquelle les probl` emes et les complaintes exprim´ ees par les UDI ´ etaient caus´ ees par leur
statut d’usagers de drogues.
En 2005, 60 trabajadores del sector de la salud fueron encontrados a trav´ es de servicios
que atraen a los usuarios de drogas inyectables (UDI) y les pidieron completar medidas de
actitud en cuanto a clientes UDI. Los an´ alisis de mediaci´ on indicaron que los trabajadores
conservadores del sector de la salud revelaron actitudes m´ as negativas hacia los clientes
UDI debido a que ellos creen que el uso de drogas inyectables est´ a dentro del control de
los usuarios de drogas inyectables. Las actitudes negativas hacia los clientes UDI fueron
asociados con la preocupaci´ on acerca del comportamiento de los clientes UDI en la cl´ ınica
y con la creencia de que los clientes UDI deber´ ıan revelar sus estatus de hepatitis C. Las
percepciones de la habilidad del control del uso de drogas tambi´ en fueron asociadas con la
creencia que las dolencias de los clientes UDI fueron causadas por sus estatus UDI.
Loren Brener isa research associate atthe National Cen-
tre in HIV Social Research, University of New South
Wales. Her research focuses on injecting drug use, hep-
atitis C and equitable treatment, and access and care for
people who use illicit substances. She has also worked in
South Africa conducting HIV/AIDS prevention research
with sex workers and cofounded a research unit focusing
on understanding the health and psychosocial needs of
street-based sex workers.
1016 Brener et al.
William von Hippel is a professor of psychology at the
University of Queensland. Prior to his arrival at Univer-
sity of Queensland he served on the faculty for five years
at the University of New South Wales and for twelve
years at Ohio State University. His research activity has
been primarily in the area of stereotyping and prejudice,
where most of his work concerns the cognitive under-
pinnings and consequences of stereotyping. He also con-
ducts research on social cognitive aging and executive
Susan Kippax. Since retiring from the Directorship of
the NCHSR, Professor Kippax is employed as a Pro-
fessorial Research Fellow. She is Chief Investigator on
a number of studies including exploring the role of the
Internet in building social capital among gay men, inves-
tigating the ways in which general practice deals with
depression in gay men, and documenting ‘resilience’ in
prevention-treatment nexus and the ways in which poli-
cies concerning HIV-treatment roll out and HIV-testing
play out in relation to prevention within modern public
Kristopher J. Preacher is an assistantprofessor of quan-
titative psychology at the University of Kansas. His re-
search focuses primarily on the use of factor analysis,
structural equation modeling, and multilevel modeling to
analyze longitudinal and correlational data. Other inter-
ests include developing techniques to test mediation and
moderation hypotheses, bridging the gap between theory
and practice, and studying model evaluation and model
selection in the application of multivariate methods to
social science questions.
Bivariate correlations: Measure of the strength of the relationship between two variables.
Bootstrapping: A method of estimating standard error and significance based not on as-
sumptions of normality but on empirical resampling with replacement of the data.
Conservatism: A preference to maintain the existing or traditional order.
Hepatitis C: Inflammation of the liver due to the hepatitis C virus (HCV), which is usually
spread by blood transfusion, hemodialysis, and needle sticks. The damage it does to
the liver can lead to cirrhosis and cancer.
Attitudes of Health Professionals in the Health Care of IDUs1017
Injecting drug use: The client’s use of injection as a method of administering illicit or
prescription drugs; includes intravenous, intramuscular, and subcutaneous forms of
Path analysis: An extension of the regression model that can be used to test for mediation.
Path coefficients: Measure of the strength of a given path of influence that is theorized to
be from cause to effect.
Perception of Control: A social theory proposing that individuals believe that they have
power and control over the events that occur in their lives.
the likelihood of desired health outcomes and are consistent with current professional
knowledge and practice.
Regression analyses: A statistical technique used to estimate the unique effect of one
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