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| 3965 KNOWLEDGE AND ATTITUDES TOWARD HIV AND PEOPLE LIVING WITH HIV (PLWH) AMONG PUBLIC HEALTH MIDWIVES IN THE GALLE DISTRICT, SRI LANKA

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5-3 98 2 | Se t em b ro /D ez e mb ro-2020 IS SN 1 9 80-57 56 | D OI: 1 0. 21 17 1/ g es .v 1 4 i40. 33 3 7 Su k et. A l. Su b m etid o e m 08 de J u n h o d e 2 0 2 0. Ap rov ad o e m 30 de J u lh o d e 2 02 0. Ap rov ad o p e la E d itor ia Ci en t í fi ca. w an Pra s ad Ar av in d a 3 , Vij ith a De si lv a 3 , S h a yn a Cl an c y 4 , L .G a yan i Till e ke rat n e 2 , Tru l s Ø st b ye 2 , 4 1-Nat ion a l H ea lth In su r an ce S er v ic e o f Ko r e a, Wo n ju , S ou th Kor e a 2-Du k e G lob al Hea lth In st itu t e, D u r h am , Nor th C ar ol in a , U S A 3-Dep ar tm en t o f Co m m u n it y M e d i cin e , Un i ver s it y of Ru h u n a , Sr i L an k a 4-Dep ar tm en t of Fam i l y M ed i cin e an d Co m m u n i ty He al th , Du ke Un iv er si ty M ed ica l Cen ter , Du r h am , Nor th C ar o lin a , US A ABSTRACT This cross-sectional study aimed to assess HIV-related knowledge and attitudes of PHMs, the frontline community health workers in Sri Lanka. Two-hundred and ninety-one P HMs were recruited. PHMs' kno wledge level was good (79.9% of answers were correct) but could be improved. Those more knowledgeable about HIV and with higher education demonstrated a more positive attitude t oward PLWH. A more negative attitude, less training and older age were associated with having a stronger intention to engage in extra precautionary behaviors. PHMs need further HIV training to improve their knowledge to better educate the community. By reducing PHMs misperceptions about HIV, they may develop a more positive attitude and thus help reduce the general public's stigma asso ciated with PLWH. 5-3 98 2 | Se t em b ro /D ez e mb ro-2020 IS SN 1 9 80-57 56 | D OI: 1 0. 21 17 1/ g es .v 1 4 i40. 33 3 7 Su k et. A l. Su b m etid o e m 08 de J u n h o d e 2 0 2 0. Ap rov ad o e m 30 de J u lh o d e 2 02 0. Ap rov ad o p e la E d itor ia Ci en t í fi ca. | 3966 RESUMO Este estudo transversal teve como objetivo avaliar o conhecimento e as atitudes d as parteiras na saúde pública (PHMs) em relação ao HIV, os profissionais de saúde comunitários da linha de frente no Sri Lanka. D uzentos e noventa e um a PHMs foram recrutadas. O nível de conhecimento das PHMs era bom (79,9% das respostas estavam corretas), mas po deria ser melhorado. Aqueles mais bem informados sobre o HIV e com educação superior demonstraram uma atitude mais positiva em relação às pessoas que vivem com HIV (PLWH). Uma atitude mais negativa, menos treinamento e maior idade foram associados a uma intenção mais forte de se envolver em comportamentos de precaução extra. As PHMs precisam de mais treinamento em HIV para melhorar seus conhecimentos e educar melhor a comunidade. Ao reduzir as percepções equivocadas das PHMs sobre o HIV, eles podem desenvolver uma atitude mais positiva e, assim, ajudar a reduzir o estigma do público em geral associado às PLWH. Palavras-chav e: HIV, P LWH, estigma, atitude, agentes comunitário s de saúde, parteiras, Ásia, Sri Lanka .
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Revista Eletrônica Gestão & Soc iedade
v.14, n.40, p. 3 965-3982 | Set embro /Dezembro 2020
ISSN 1980-5756 | D OI: 1 0.21171/ges.v 1 4i40.333 7
Suk et. Al.
Submetido em 08 de Junho de 202 0.
Aprovado em 30 de Julho d e 2020.
Aprovado pela Editoria Ci ent í fica.
| 3965
KNOWLEDGE A N D ATTITUDES TOWARD HIV AND PEOPLE LIVING WITH HIV (PLWH) AMONG
PUBLIC HEALTH MIDWIVES IN THE GALLE DISTRICT, SRI LANKA
Jihye Suk1 , 2 , Nuwan Pras ad A r a v i n d a 3, Vijitha Desilva 3, Sh a y n a C l a n c y4, L.Gayani
Tillekeratne2, Truls Ø s t b y e 2 , 4
1- National Health Insurance Serv ice of Kore a, Wonju, South Korea
2- Duke Global Health Institute, D urham, North Carolina, USA
3- Department of Commun ity Medicine , University of Ru huna, Sr i Lanka
4- Department of Family Medicine and Co mmun ity He al th , Du ke Un iv ersity Medical Ce nter, Du rh am,
North Carolina, USA
ABSTRACT
This cross-sectiona l study aimed to assess HIV-related knowledge and attitudes of PHMs, the
frontline community health workers in Sri Lanka. Two -hundred and ninety -o ne PHMs were
recruited. PHMs knowledge level was good (79.9% of answers were correct) but could be
improved. Those m o re knowledgeable about HIV and w it h higher education demonstra t e d a more
positive att i t u de toward PLWH. A more negative att i t u de, less training and older age were
associate d wit h having a stronger intention to engage in extra precautionary behaviors. PHMs
need further HIV training t o improve t heir knowledge to better educ a t e the co m m u n ity. By
reducing P HMs mispe r ceptions about HIV, they may develo p a m ore positive attitude and thus
help reduce t h e general publics stigma associated with PLWH.
Keywords : HIV, PLWH, Stigma, attitude, community he alth workers, midwives, Asia, Sri Lanka .
Revista Eletrônica Gestão & Soc iedade
v.14, n.40, p. 3 965-3982 | Set embro /Dezembro 2020
ISSN 1980-5756 | D OI: 1 0.21171/ges.v 1 4i40.333 7
Suk et. Al.
Submetido em 08 de Junho de 202 0.
Aprovado em 30 de Julho d e 2020.
Aprovado pela Editoria Ci ent í fica.
| 3966
RESUMO
Este estudo transversal teve como objetivo avaliar o conhecimento e as atitudes d as parteiras na
saúde pública (PHMs) em relação ao HIV, os profissionais de saúde comunitários da linha de
frente no Sri Lanka. Duzentos e noventa e uma PHMs foram recrutadas. O nível de conhecimento
das PHMs era bo m (79,9% das respostas esta vam corretas), mas poderia s e r melhorado. Aqueles
mais bem informados sobre o HI V e com e ducação su per io r demonstraram uma atit u de mais
positiva em relação às pessoas que vi v e m com HIV (PLWH) . Uma atitude mais negativa, menos
treinam ento e maior idade foram associados a um a intenção ma is forte de se envolver e m
comportamentos de precaução extr a . As PHMs precis am de mais treinamento em HIV para
melhorar seus c o n he c im entos e educar mel ho r a comunidade. Ao reduz i r as p e rcepções
equivocadas das P H M s sobre o HIV, eles podem desenvolver uma atitude mais positiva e, assim,
ajudar a reduzir o estigma do público em geral a s sociado às PLWH.
Palavras -chav e: HI V, PLWH, estigma, atitude, agentes comuni t ários de saúde, parteiras, Ásia,
Sri Lanka.
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INTRODUCTION
Stigma associated with HIV and people living
with HIV (PLWH) has been prevale nt since t h e
HIV epidemic started in the 1980s. In
particular, the experiences of discrimination
and stigmatization in h e a l t hc are settings
weaken peoples wil li n gness to engage i n HIV
testing, disclose HIV s ta t us, request care and
comply with t r e atment1.
Even thoug h early studies sho wed that
factors such as age, g ender, education,
knowledge , an d religion did not show
consistent associations with healthcare
workers negative attitude toward PLWH 2,
some studies did s ho w associations between
such factors and n egative atti t ude. In
general, heal t hcare workers who are o l der,
less trained and less knowledgeab le, have
more fear of infection and t hose w ho have
less contact with P L W H tend to demonstrate
more negat i v e att i tu d e s 37.
Although t h e number of new HIV infections
and PLWH has bee n increasing in Sri L anka
since 1990, few st udies ha v e been done i n
the cou ntry of this t o pic. Even though so m e
studies have examined the association of
factors with healthcare workers stigma
associate d w ith HIV, community health
workers attitudes have not been studied
much. Since Sri L ankan Pu b l ic Healt h
Midwives’ (PHMs) in teraction with people
living in the community now extend beyon d
midwifer y , i t is important to know whether
PHMs are knowledgeable a nd trained to
reach out to PLWH. This topic is particularly
interest ing to study in the G al le District a s it
has had a high cumulative rate of reported
HIV cases per 100,000 populations from 1987
to 2015 (6th out of 25 districts)8.
This study first aimed to assess PHMs
knowledge and attitudes toward PLWH in the
Galle District in Sri La nka. Second, the study
sought to examine factors associated with
such k nowledge, attit udes and st i gma, and
third, to assess the ass o c iation o f knowledge,
attitude, stigma w i t h e n g ag in g in extra
precautiona ry behaviors.
METHODS
STUDY SETTING AND PARTICIPANT
RECRUITMENT
This cross - s ectio nal study was co n ducted in
the Galle District, Sri Lanka fr o m June 2015
to August 2015. Participants consisted of 291
PHMs working in t h e Galle District. This
includes nearly all PHMs of the Galle District
except t ho se who were not present at o n e o f
their monthly meetings due t o sickness,
maternity l e ave or other personal reasons.
PROCEDURES
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Two questionnaires were adapted for this
study. First, t o assess a tt itudes toward
people living with HIV, a standardized brief
questionna ire measuring st i gma and
discriminatio n among health facility staff
was adapted 9. This questionnaire was chosen
to assess healthcare workers attitudes and
to allow the results to be c o m p ared across
other regions and countries. Second, to
measure the k no w le d g e level of PHMs, th e
18-item HIV Knowledge Questionnaire ( HIV-
KQ-18) was utilized10. Th e questions focus o n
sexual transmission of HIV a n d has previously
been used among low income, low lit e racy,
heterosexua l subjects10. Before translating
the En g l is h version of these 2 questionnaires
into S i n h a lese, a f ew changes w ere made t o
fit the l o c a l setting. Data were collected
during the PHMs’ monthly me e ting, and th e
procedures w e r e a p p rov ed by the ethics
review boards at Duke University and t h e
University o f Ruhuna.
MEASURES
Drivers of HIV -re lated stigma
Characteris t ics o f P ar t icipants. T he PHMs
age, e d u cation level, marital stat us, religion,
years of ex per ience in healthcar e , HIV clinic
and HIV traini ng experience were reported.
Knowledge . Two quest io ns fro m the HIV-KQ-
18 were deleted: one questio n was deemed
sensitive co ntent i n the Sri Lanka setting
(Pulling out the penis before a m a n
climaxes/cum s k e e p s a w o m a n fr om getting
HIV d u r i n g sex.) , and one (A n a t u r a l ski n
condom w orks better a g a i n s t HIV t h a n does a
latex condom) appeared less relevant since
natural skin condoms are not com monly
available in Sri Lanka. Part of one question
(putting t heir tongue in t h e i r p a r t n e r s
mouth) was also deemed culturally sensitive
and delet e d.
HIV-relate d stigma.
Secondar y stig m a . (3 item s ) Sti gma toward
the PHMs from others ( f rie n ds, f amily,
colleagues) du e to the i r care for PLWH were
asked.
Attitude t o PLWH. (5 items) Partic i pa nts
stated their opinions in 5 item s that
negatively de scribe PLWH (e.g., P e o p l e li ving
with HIV s h o u l d f e el as h amed o f th e m s elves,
HIV is p u n i s h m e n t for b a d behavior) on a
scale f ro m 0 (Strongly disagree) to 3
(Strongly agr e e ) .
Attitude t o p r e g n a n t w o m e n with HIV. ( 5
items) P a rt i c ipants gave their opinion t o 4
items that n eg atively describe pregnant
women with HIV (e.g., Pregnant w o m e n wh o
refuse HIV te s t i n g are ir r e s p o n s ible, Wo m e n
living wi t h HIV should not get pr e g na n t i f
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they a l r e a d y have c h i l d r e n ) on the scale fro m
0 (Strongly d isagree) to 3 (Strongly agre e ) .
Attitude to a t - r i s k p o p u l a t i o n . ( 4 items) At-
risk populations were defined as people who
inject ill eg al drugs, men who have sex wit h
men and female/male sex w o rkers. Items
assessed their willingness to treat the at - risk
populatio ns. If they agreed or strongly
agreed on not pr o v id i n g treatment to these
groups, additional reasons fo r that answer
were giv e n .
Consequence of HIV -re l ated stigma.
Extra infection precaution. (4 items)
Participant s were asked whether they use
extra pre c autions (e.g., double gloves,
special infection - c o nt r o l supplies) that the y
usually d o not use when they treat patients
who do not ha v e HIV.
ANALYSIS
After t a b u l ati ng summary statistics o f
participant characteristics, k n o w led ge level
was calculated by summing correct a n s w e r s .
To identify underlyin g attitude and stigma
factors, an ex p loratory factor analysis (E FA )
was conducted. Items having the same
answer format were kept and used fo r the
EFA. Six items asking about facility p o licy and
other healthcare workers were excluded
since they di d reflect PHMs attitudes nor
stigma to w a rd PLWH. Four items measur ing
fear were also excluded due to many
missing v al ues. F o u r items asking extra
infection preca utio n w e re deliberately
exclude d and instead considered to be
conseque nces of HIV-related stigma.
After obtaining 4 meaningful
attitudes/st i gma factors, the as s o c iation
between characteristics of pa rticipants and
knowledge level wer e examine d . Th e re after,
to assess how characteristics o f participants
and knowledge level were associated with
attitudes/st i gma factors, t - t e st and Anova
test were used. A multiple linear regressio n
model was used to predict each of t h e 4
factor scores by age, job category, marital
status, education level, HIV clinic experience,
training and k nowledge level.
Finally , lo g istic reg res sion analysis was used
to assess the relationship of characteristics
of participant s, knowledge and
attitudes/st i gma factors with 4 extra
precautiona ry behaviors (avoiding physical
contact, using double glove whe n treating
PLWH, using gloves all the time and us i ng
special meas u re s when treat PLWH) .
RESULTS
PARTICIPANTS
PHMs were quit e homogenous in terms o f
religion, marital st atus, e d ucation and
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experience in taking care of HIV patients.
Most PHMs we r e B uddhist (99.3%), married
(94.8%), high school graduates (8 3 .8 %), had
no experience in a HIV-clinic (96.9%) and had
not seen any PLWH in the past 12 months
(99.6%). O nly 1 P HM answered t hat she had
observed 1 H IV patient in the past year.
Most PHMs had extens i v e w o rki n g
experience but had not received m an y
trainings related with HIV. Mea n age was
44.2±9.7 years (min: 2 7 , max: 62) and
average y e ar s of w o rking as PHM was
16.9±8.6 years (min: 1.5, max: 34). Only 17%
had re ceived training about HI V stigma and
more than half (5 4 . 6 % ) had never received
any training about any of the f o l lowi n g
subjects: HIV stigma, infe c tion control,
patients confidentiality and stigma toward
at-risk populat ion.
HIV-RELATED KNOWLEDGE
Table 1 presents the 16 questions that wer e
asked of PHMs and their answers, as well a s
whether the answer was correct. The m e a n
number of cor rect answers was 12.8±1.9
(min: 4, max: 16) out of 16 ( 𝛼 =0.4 6 ) . As
inferred fro m t he average score, PHMs w e r e
generally kn o w ledgeable of HIV
transmis sions, but there w a s some confusion
relating to a few items. Approximately one in
five PHMs in co rre c tly answered tha t
Coughing and sneezing could spread HIV
(22.3%),All pr e gnant women with HIV will
have a b a b y born with HIV (23%) a nd U s i n g
Vaseline or baby oil w i th co nd oms co ul d
lower the ch an ce o f getting H IV (23.7%).
Almost 30% inc o r r ec t l y answered that a
person cannot get H IV f ro m o ral sex.
There were some it e m s where a fair number
of PHMs did no t know if the statement was
true or false. Approximately o ne in four o f
respondent s answered that t h ey d o n t
know whether Taking a test for HIV one
week after sex will tell a person if she/he has
HIV (24.1%) which is a false statement.
Nearly one third of PHMs did not know
whether t here exists an HIV vaccine.
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Table 1 | Knowledge (n=291)
Item
Wrong
Don't know
Having sex with more than one partner can increase a person’s chance of being infected with HIV (T)
2.4%
1.4%
Showering, or washing one’s genitals/private parts, after sex keeps a person from getting HIV (F)
1.7%
2.4%
A person can get HIV by sitting in a hot tub or a swimming pool with a person who has HIV (F)
2.1%
3.4%
People are likely to get HIV by kissing, if their partner has HIV (F)
5.2%
1.4%
A person can get HIV by sharing a glass of water with someone who has HIV (F)
7.9%
2.4%
A person will NOT get HIV if she or he is taking antibiotics (F)
1.7%
8.9%
People who have been infected with HIV quickly show serious signs of being infected (F)
6.5%
4.8%
A woman cannot get HIV if she has sex during her period (F)
5.5%
6.5%
A woman can get HIV if she has anal sex with a man (T)
8.6%
8.9%
There is a female condom that can help decrease a woman’s chance of getting HIV (T)
7.9%
10.7%
Coughing and sneezing DO NOT spread HIV (T)
22.3%
2.7%
Taking a test for HIV one week after having sex will tell a person if she or he has HIV (F)
5.8%
24.1%
There is a vaccine that can stop adults from getting HIV (F)
4.5%
32.3%
A person can get HIV from oral sex (T)
28.9%
10.0%
All pregnant women infected with HIV will have babies born with HIV (F)
23.0%
15.8%
Using Vaseline or baby oil with condoms lowers the chance of getting HIV (F)
23.7%
24.1%
Total score
9.9%
10.0%
Source: authors’ own.
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FACTOR ANALYSIS OF HIV-RELATED
ATTITUDES AND STIGMA SCALE
After conducting EFA with 17 items (187
observatio ns), 4 attitude s/stigma factors
were obtained: A ttit u d e to at -risk po pulation
(Factor 1), Attitude to people living with HIV
(Factor 2), Secondary st igma (Facto r 3), and
Attitude to reproduction among pregn a nt
women with HIV (Factor 4). After orthogonal
rotation (varimax), each participants
standardize d factor score (mean=0, s.d .=1)
was obtained, representing the e x t e nt of
PHMs negative attitu des and stigma (higher
factor scores indicate more negative
attitudes and w o rs e st igma).
Attitude to at - risk p o pulations (Factor 1)
included participants ’ willingness to interact
with individuals who are considered at -risk.
The mo re reluctant they were to i nteract
with these groups, the higher their score s
were for this factor. Attitude to PLWH (Factor
2) included ster e o types and negative
emotional reactions ( e .g. bla m e , sham e ) to
PLWH, including pregnant women. The mo re
negative attitudes a nd stronger negative
beliefs about PLWH reported, t he higher th e
scores. Seco nda ry stigma (Factor 3 ) is stigma
experienced from the public , friends, family
and colleagues due to caring fo r PLWH ( High
score indicates PHMs worry and care a lot o f
other peoples reaction to themselves). Th e
last factor, attitude t o reproduction,
indicates attitude to pregnancy in wo m e n
living with HIV ( h i gh e r score means highe r
stigma relating to reproducti o n in HIV
positive wo men).
PREDICTORS O F KNOW LE D G E, ATTITUDE S A N D
STIGMA RELA T ED T O HIV/AIDS (BI V A R I A T E
ANALYSES)
Parametric test (Two - sample t-test or a one
way Anova test) was used to test if there
were any differences be t w e e n/among groups
in terms of their kno wledge, attitudes and
stigma.
As presented in Tabl e 2a, significant
differenc e s i n k no w l e dge were found
between the group that had received at l east
1 training an d the group that had r eceived no
training=13.02 vs. 12.60, p<0.05). Amo n g
age groups, significant di f fere nces were
found fo r 2 f a ctors : attitude to PLWH
(p<0.001) and secondary s tigma (p<0.05).
Educat ion level was also one of the
significant predictors. Attitude to at-risk
populatio ns (p<0.05) and reproduction in
pregnant women with HIV (p<0.01) were
significan t ly d i ffe r ent by education level.
Years of working ex p e rience w a s divided into
4 groups and showed significant difference o f
attitude toward PLWH ( p< 0 .001) among the
groups. Participants who had worked more
than 20 years s ho w e d more negative
attitudes th an those who had worked less.
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PREDICTORS O F KNOW LE D G E, ATT ITUD E S A N D
STIGMA R E L A T E D T O H I V /AIDS (MU L T I P LE
LINEAR REGRESSION)
In t h i s m u lt i p l e l inear regression model,
knowledge level was a dded as a p redictor of
attitudes/st i gma factor while all the
predictors th at were used in the bivariate
analyse s were kept.
As p rese nted in Table 2b , training (ß=0.468,
p<0.05) remained a significan t an d positive
predictor of knowledge. More knowledge w a s
positively associated with better attitude
toward at-risk population ( ß= - 0 . 1 2 5 , p<0.05)
and lower secondary st i gma (ß=-0.105,
p<0.05). Age a n d education level a l s o
remained significant predictors of secondary
stigma and at t itude to repro duction. P HMs
older than 50 ( ß= -0.877, p<0.05) showed
lower secondary stigma compa r ed to those
under 30 . A m o r e positive attitude to
reproductio n of HIV positive women was
observed for PHMs with higher education,
including high sc h o o l (ß= -0 . 8 1 9 , p<0.05) and
college (ß=-1.525, p<0.01), co m pared to
those with a middle school education.
While y e ars of wo rk i n g experience di d not
remain significant i n the m o del, marital
status beca m e a significant predictor.
Married (ß=0.444, p <0.01) PHMs showed
higher secondary stigma compared t o
unmarried PHM s .
CONSEQUENCES OF KNOW LE DG E, AT T I T U DE S ,
STIGMA AND OTHER FACTORS
The relationships of predictors (knowledge,
attitudes, stigma, demographic information)
with the ex t r a precautionary behaviors ar e
summarize d in the Table 3.
In unadjusted logistic re gression, PHMs wh o
have m o r e negative a t t i tudes toward at-risk
populatio ns (OR=2.24; 95% CI 1 .4 4 -3.49) and
PLWH (OR=1.65; 95% CI 1.01 -2.68) were m o r e
likely to avoid physical contact with PLWH.
Older PHM s a lso showed higher odds
(OR=2.52; 95% CI 1.03-6.15) of avoiding
physic al contact th a n the younger PHMs. In
contrast, the more k nowledgeable they were,
the less likely were they to avoid phy s i c a l
contact with PLWH ( O R = 0 .79; 95% CI 0.66-
0.94).
Similarly , PHMs having more negative
attitudes toward PL W H (OR=1.67; 95% CI
1.19-2.34) and o lder PHMs (OR=5.61; 95% CI
2.93-10.75) w e r e more likely to we ar glo v es
during all the aspect o f care . On the contrary,
having at l e ast 1 training was associated with
the lower odds of we a ring glove all the time
(OR=0.41; 95% CI 0 . 1 9 -0.92).
In the adjusted logistic regression model,
attitudes toward at-risk population, toward
PLWH, an d age re m ained as significant
predictors f o r avoiding physical co ntact and
for wearing g lo v e s dur i n g all the as pect of
care.
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Table 2a | Predictors of knowledge, attitudes and stigma related to HIV/AIDS (Bivariate)
Knowledge
Attitude to
at-risk population
Attitude to PLWH
Secondary
stigma
Attitude to reproduction
Predictors
n
mean
(s.d)
p
n
mean
(s.d)
p
mean
(s.d)
p
mean
(s.d)
p
mean
(s.d)
p
Age
under 40
112
12.87
(1.88)
70
0.01
(0.92)
-0.26
(0.96)
0.24
(1.27)
-0.10
(0.96)
40-49
71
13.10
(2.03)
47
-0.24
(0.77)
-0.28
(0.86)
0.00
(0.94)
-0.18
(1.02)
50+
107
12.49
(1.76)
69
0.16
(1.18)
0.43
(0.97)
***
-0.24
(0.63)
*
0.20
(0.99)
Professional category
SPHM
15
12.33
(1.50)
9
-0.03
(0.52)
0.51
(0.70)
0.14
(1.10)
-0.06
(1.08)
PHM
276
12.81
(1.90)
178
0.00
(1.02)
-0.03
(1.01)
-0.01
(1.00)
0.00
(1.00)
Marital status
Single
15
13.27
(1.39)
11
0.23
(1.43)
0.15
(1.11)
-0.39
(0.22)
0.01
(0.74)
Married
276
12.76
(1.90)
176
-0.01
(0.97)
-0.01
(1.00)
0.02
(1.02)
0.00
(1.02)
Education
ordinary
12
12.58
(2.27)
7
0.35
(1.41)
0.49
(0.82)
-0.37
(0.15)
0.97
(0.59)
advanced
244
12.74
(1.89)
160
-0.07
(0.94)
0.01
(1.01)
-0.02
(0.94)
0.02
(0.98)
diploma
23
13.22
(1.65)
14
0.28
(1.18)
-0.33
(1.04)
0.30
(1.33)
-0.63
(0.88)
graduate
12
13.08
(1.68)
6
0.93
(1.14)
*
-0.02
(0.62)
0.41
(1.99)
-0.12
(1.33)
**
Working experience
less than 10
92
12.82
(2.01)
55
0.07
(0.97)
-0.33
(1.02)
0.16
(1.24)
-0.12
(1.02)
10-19
71
13.11
(1.73)
50
-0.16
(0.93)
-0.22
(0.79)
0.12
(1.11)
-0.05
(0.91)
20-29
112
12.59
(1.88)
73
0.05
(1.06)
0.36
(1.02)
-0.19
(0.68)
0.08
(1.05)
30+
16
12.56
(1.71)
9
0.07
(1.05)
0.36
(0.74)
***
-0.12
(0.78)
0.38
(0.88)
HIV clinic experience
Yes
9
13.67
(1.12)
6
0.06
(1.04)
-0.49
(1.14)
0.79
(1.65)
-0.47
(0.60)
No
279
12.76
(1.90)
180
0.00
(1.00)
0.02
(1.00)
-0.03
(0.97)
*
0.02
(1.01)
Training
At least 1 training
132
13.02
(1.74)
95
0.04
(1.09)
0.05
(0.97)
0.07
(1.12)
0.08
(1.00)
None
159
12.60
(1.97)
*
92
-0.04
(0.90)
-0.05
(1.03)
-0.08
(0.86)
-0.08
(1.00)
*p<0.05, **p<0.01, ***p<0.001
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Table 2b | Predictors of knowledge, attitudes and stigma related to HIV/AIDS (multiple linear regression)
Knowledge
Attitude to at-risk
population
Attitude to PLWH
Secondary stigma
Attitude to
reproduction
Predictors
Coef.
(S.E.)
p
Coef.
(S.E.*)
p
Coef.
(S.E.)
p
Coef.
(S.E.*)
p
Coef.
(S.E.)
p
Age (ref. under 30)
40-49
0.17
0.51
0.15
0.26
-0.38
0.30
-0.43
0.39
-0.27
0.31
50+
-0.38
0.62
0.53
0.39
0.10
0.37
-0.88
0.43
*
0.15
0.38
PHM
0.21
0.54
0.20
0.25
-0.07
0.35
-0.38
0.34
0.26
0.36
Married
-0.43
0.52
-0.14
0.39
-0.19
0.31
0.44
0.16
**
-0.09
0.32
Education(ref. middle)
Advanced level(high)
0.04
0.59
-0.19
0.43
-0.17
0.40
0.24
0.15
-0.82
0.41
*
Diploma(college)
0.42
0.74
0.25
0.55
-0.25
0.50
0.41
0.42
-1.53
0.51
**
Graduate
0.26
0.82
0.79
0.57
0.00
0.57
0.60
0.70
-0.97
0.58
HIV clinic experience
0.68
0.64
0.15
0.45
-0.33
0.40
0.83
0.64
-0.39
0.41
Working experience(yr)
less than 10
0.37
0.47
-0.26
0.22
0.35
0.28
0.30
0.38
0.13
0.29
10-19
0.15
0.62
-0.36
0.35
0.64
0.38
0.38
0.44
-0.03
0.39
30+
0.32
0.81
-0.39
0.48
0.51
0.52
0.72
0.52
-0.01
0.53
At least 1 training
0.47
0.23
*
0.07
0.16
0.06
0.15
0.25
0.15
0.16
0.15
Knowledge
-0.12
0.05
*
-0.05
0.04
-0.11
0.05
*
0.00
0.04
R square
0.05
0.12
0.15
0.13
0.10
Numer of observations
287
185
Source: authors’ own.
Notes:* Robust regression was used in two models (attitude to at-risk population, secondary stigma) to manage heteroscedasticity in their results.
*p<0.05, **p<0.01, ***p<0.001
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Table 3 | The relationship of knowledge, attitudes, stigma, demographic predictors with the precautionary behaviors (unadjusted and adjusted logistic regression)
Avoid physical contact
Wear glove all the time
Wear double glove
Use
special measure
OR(95% CI) p
Predictors
Unadjusted
Adjusted
Unadjusted
Adjusted
Unadjusted
Unadjusted
Attitude to at-risk pop.
2.24
(1.44-3.49)
***
2.18
(1.28-3.69)
**
1.33
(0.96-1.83)
1.45
(0.95-2.21)
1.04
(0.72-1.49)
1.07
(0.76-1.51)
Attitude to PLWH
1.65
(1.01-2.68)
*
1.61
(0.88-2.95)
1.67
(1.19-2.34)
**
1.62
(1.06-2.45)
*
1.11
(0.78-1.57)
1.05
(0.75-1.46)
Secondary stigma
1.29
(0.87-1.91)
1.48
(0.90-2.45)
0.97
(0.70-1.34)
1.08
(0.74-1.57)
0.81
(0.59-1.13)
1.18
(0.81-1.72)
Attitude to reproduction
1.12
(0.69-1.81)
0.93
(0.53-1.66)
1.33
(0.96-1.85)
1.42
(0.95-2.10)
1.26
(0.88-1.81)
1.26
(0.89-1.78)
Knowledge
0.79
(0.66-0.94)
**
1.05
(0.74-1.49)
0.89
(0.77-1.03)
1.08
(0.84-1.39)
0.92
(0.78-1.08)
0.90
(0.76-1.07)
Age
under 30
1.00
1.00
1.00
1.00
1.00
1.00
40-49
1.81
(0.66-4.95)
4.11
(0.69-24.68)
1.61
(0.77-3.37)
0.88
(0.30-2.61)
1.60
(0.78-3.30)
1.13
(0.55-2.32)
50+
2.52
(1.03-6.15)
*
2.83
(0.45-17.65)
5.61
(2.93-10.75)
***
4.62
(1.77-12.02)
**
2.19
(1.09-4.38)
*
1.46
(0.75-2.85)
Education
Ordinary level
1.00
1.00
1.00
1.00
1.00
Advanced level(high)
0.49
(0.10-2.48)
0.28
(0.02-3.52)
0.68
(0.20-2.30)
2.31
(0.28-18.70)
1.16
(0.23-5.78)
1.32
(0.33-5.27)
Diploma(college)
0.37
(0.04-3.14)
0.22
(0.00-10.28)
0.28
(0.06-1.41)
2.56
(0.16-41.86)
0.35
(0.06-2.12)
0.93
(0.18-4.90)
Graduate
0.78
(0.09-6.98)
0.98
(0.04-26.77)
0.45
(0.08-2.67)
2.11
(0.11-39.44)
0.76
(0.10-5.96)
_
Married
0.51
(0.13-1.92)
0.30
(0.05-1.94)
_
_
1.31
(0.40-4.28)
2.20
(0.75-6.44)
At least 1 training
1.54
(0.75-3.18)
1.88
(0.59-6.03)
0.60
(0.35-1.01)
0.41
(0.19-0.92)
*
0.54
(0.30-0.96)
*
1.51
(0.85-2.70)
Source: authors’ own
Notes: *p<0.05, **p<0.01, ***p<0.001
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DISCUSSION
This study assessed PHMs HIV-related
knowledge and attitudes toward PLWH. Even
though these PHMs h a d very little experience
with PLWH, their knowledge level was
generally good. They provided 79.9% correct
answers to the knowledge questions (16
items). Those more knowledgeable a bout H I V
and with higher education demonstrated a
more positive attitude toward PLWH. PHMs
who were older, had l ess training o r had a
more n e gative attitude, showed a stronger
intention to engage in extra precautionary
behavio rs.
KNOWLEDGE
Sri Lankan PHMs kno wledge le v e l was within
the range that has been observed in other
studies f rom other Asian countries: from
Indonesia ( 6 9 .4%), B a ngladesh (78%), Fiji
(80%), s o u t h Korea (8 5 . 9 % ) that ut il ize d the
same questionnaire ( HIV-KQ-18) wi t h similar
populatio ns, such as nurses or n ur sing
students6 , 1 1 13.
FACTORS A S S O C I A T E D WI T H AT T IT U DE S AND
STIGMA
Knowledge . Participants w ith higher
knowledge showed a more po s itive attitude
and lower s t igma toward PLWH. This is
consistent w i th the associations with
knowledge and attitude found in previous
studies5 , 1 4 .
Age and education. Older participants te nde d
to have more negative a t t it udes toward
PLWH and at-risk populations but also
showed less secondary stigma than yo u nger
participant s . This is comparable with
previous studies from elsewhere showing
older participants hav e more ne gative
attitude toward PLWH than their younger
counterpart s 5 , 6. However, t hese associations
have not been c o n si stent: in a systematic
review, some studies indicate d that se nior
healthcare work e r s had better attitude to
PLWH, whi le in others, younger health care
workers s h o w e d more po s i t i v e a t t it u d e
toward at-risk po pulat ions 2. O ur results m a y
be due to the fact that education level is
more influential than age per s e , with o lder
participants having lower education.
Although the older participants had more
negative attitudes toward P LWH, they
exhibited l e ss secon da ry stigma. This may be
in part because t h e y have more w o r k
experience a n d may be mo re familiar wi t h
the communit y m e m b ers.
Marital status. Marrie d PHMs demonstrated
higher secondary s t igma t ha n those who
were single. This result is comparable with
previous studies5 , 1 4 : married healthcare
workers in Indo ne s i a showed mo r e negative
attitude than the single workers 5 and medica l
students in Vietnam having more family
members showed more negat i v e attitude14.
Having more family members might lead t o
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more cautious attitude s to ind i v i d ua l s
outside t he family.
ASSOCIATIONS O F KNOWLEDGE , ATTITUDES
AND STIGMA WITH PRECAUTIONARY
BEHAVIORS
Participant s with more negative attitudes
and those who were o l der and l e ss trained
indicated that t hey would take mo re
precautiona ry be haviors. Sin c e most
participant s had little or no actual
experience working di re ctly wi t h PLWH, this
finding is of cou r s e only re l a t e d to
hypothetical f u t ure encounters.
Avoidance of physical c ont act. More negative
attitudes t o at-risk populatio ns was
associate d with more avoidance of physical
contact. The less the PHMs were willing t o
provide t re a t m e nt to thi s group, the m o r e
they were likely to avoid physical contact
with PLWH. On t he ot her hand, knowledge
and education level were not s t r o n g ly rela t e d
with such beha v io r s . It is likely that attitudes
play an im p o r t ant role for behavior.
Wearing gloves during al l as pects o f care. In
this case, a more negative attitude to PL W H
was associated with greater intention to
wear gloves. F urthermore, older par t icipants
had gre a t er intention to wear gl o v e s , while
the less t rained ones had lower intention.
IMPLICATIONS
Training will en hance knowledge and shou ld
lead to more positive attitudes toward PLWH.
Institutio nal support, such a s written po l ic i e s
and measures to protect both patients
confide ntiality a nd PHMs from infectio n,
might impr o v e P H M s attitude toward
PLWH15.
In a d d itio n, it is also i mportant to em phasize
to the PHM s t he importance of maintaining
patient c o n f i dentiality. O ne o f the major
reasons why PLWH in Sri L a n k a seek care
from n o n - government organizat i o ns (NGOs)
or other HIV-specific clinics, instead of local
clinics, was the perceived lack o f
confide ntiality in lo c a l clinics1 6 , 1 7 . However,
only 23% partic i pants had received training
on this t o pic.
STRENGTHS AND LIMITATIONS OF THE STUDY
This study provides the first analyses of HIV-
related knowledge and attitudes a m o n g
PHMs in Sri Lanka. However, the results and
implicatio ns of this study should be
interpreted with c a u tion. T he study was
cross sectional, and, si nce th e survey was is
self-administe r e d, there may be so m e social
expectatio n that influences their response s .
The study t e a m confirmed that t here is no
written policy to protect HIV patients f ro m
discrimination in the MOH; but despite this,
15.3% of participants still answered that
there a written policy exists. Finally, the
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result can only be g eneralized t o PHMs
elsewhere in Sri Lanka s i nce th e st u dy wa s
limited t o o n e district.
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