Determining of Knowledge Level of Nursing Students on HIV/AIDS

Introduction

Acquired immunodeficiency syndrome (AIDS) has been recognized as one of the most important pandemic diseases we have ever faced [1, 2]. According to 2017 report released by WHO, approximately 36.7 million people were afflicted by HIV/AIDS worldwide [3]. However, the disease has been ignored from being fatal disease, and has become a chronic disease that requires a lifelong medication use [2, 4, 5].

The WHO reported an estimated of 560,000 People Living with HIV/AIDS as well as 82,000 newly infected cases were from Mediterranean region, signifying the rapid HIV epidemics in the region. Despite the fact that there have been increased HIV/AIDS programs globally, the region scored the lowest coverage in HIV testing, treatment and prevention [6]. Similarly, the ministry of health (MoH) of Turkey indicated that the number of seropositive individuals has ascended from 1,802 in 2005 to 13,181 in 2016 [7, 8]. Study indicated the role of health education in reduction of HIV/AIDS prevalence [9]. Bektaş & Kulakaç suggested urgent implementation of large-scale HIV training programs with special emphasis on building well-trained nurses with positive attitude [10]. In doing so, health professionals particularly nurses have a potential in disseminating health education to their community on HIV/AIDS routes of transmission, manifestations, treatment methods and protective measures [11, 12].

Nurses are the principal health care givers and advocates for people infected with HIV/AIDS [13]. Although nurses are the nucleus of healthcare team, various studies discovered poor knowledge of nurses on HIV/AIDS [14]. The dearth of knowledge on HIV/AIDS poses to erroneous nursing practice and avoids provision of quality care [15]. Thus, nursing students definitely require a comprehensive education on HIV/AIDS and related issues to broaden their perspective and properly operate their caring responsibilities [16, 17]. A couple of previous studies aimed at assessing the knowledge and attitude of health sciences’ students about HIV/AIDS revealed inadequate knowledge of nurses [18, 19, 20]. Health professionals are expected to have adequate knowledge of the infection that has an integral role during providing care to HIV/AIDS patients. Hatipoğlu, et al. [19] discovered unpromising finding that more than two-third of nurses and doctors showed unsatisfactory knowledge in all aspects of the disease. Another research done by Akin S & Abolfotouh MA [21, 22] reported a substandard knowledge of nurses in regard to HIV transmission. Turkish students displayed poor knowledge with the associated exaggerated panic of contracting the infection [23, 24, 25]. Similarly, studies confırmed that Turkish undergraduate nursing students were short of knowledge on transmission and prevention aspects of HIV/AIDS [10, 26, 27].

Therefore, nursing program should encompass courses that also discover HIV/AIDS to broaden the knowledge of the students on the disease. Since education plays a foremost role in improving the knowledge of students, nurse educators should demonstrate unwavering commitment to train their students with all required and sufficient information about the disease and then to enable them provide standard-based nursing care for people Living with HIV/AIDS. Bosk & Frader [28] emphasized that understanding the perception and beliefs of healthcare workers has become a major area of interest for educational organizations and the quality of care delivered to HIV/AIDS patients.

Results

This portion of the study presents the socio-demographic characteristics, participants’ knowledge about HIV/AIDS, and relationship of the socio-demographic characteristics of the students to their knowledge level towards HIV/AIDS.

The difference of students’ knowledge in accordance to their year of study is given in Table 1. In respect of the diagnosis, nature and treatment subdivision, 93.6% of the third year and 93.3% of the fourth year students revealed that AIDS is not curable, when contrasted with 83.1% of the first and 86.9% of the second year students (p=0.001). An increased risk of infection from having a multiple sexual partners was reported by 98.2% of the fourth year students (p<0.001). It is also indicated that more proportion of 4th Knowledge related statements Year 1 n(%) Year 2 n(%) Year 3 n(%) Year 4 n(%) P x2 Statement related to HIV/AIDS transmission From infected pregnant woman to her baby during delivery 74 (46.3) 78 (64.9) 218 (87.6) 229 (82.7) 599 74.1 0 110.403 Having sexual contact with an infected person 152 (95.0) 117 (95.9) 248 (99.6) 272 (98.2) 789 97.6 0 29.868 Vaginal and seminal fluids of an infected person 135 (84.4) 107 (87.7) 222 (89.2) 249 (89.9) 713 88.2 0.027 14.208 Homosexual men have high risk of contracting HIV 80 (50.0) 67 (54.9) 157 (63.0) 161 (58.1) 465 57.5 0 31.976 HIV infected blood transfusion 138 (86.8) 109 (89.3) 236 (94.8) 252 (91.0) 735 91 0 43.938 Sharing injection needles or the surgical operation devices of an infected person 105 (65.6) 95 (77,9) 226 (90.8) 204 (73.6) 630 78 0 67.33 Sharing needles for shooting drugs, piercings, or tattoos 119 (74.4) 97 (79.5) 225 (90.4) 224 (80.9) 665 82.3 0 36.852 Statement related to HIV/AIDS prevention year than 1st year students respectively knew that drug addicts (22.0% vs 9.4%, p<0.001), homosexuals (35.0% vs 49.5, p=0.017) and adolescents (6.3% vs 32.4%, p=0.001) are among the high risk groups. However, more proportion of year one than year four students correctly knew that healthcare providers (78.1% vs 51.6%, p<0.001) and married women (88.1% vs 72.9%, p<0.001) are not among the high risk groups.

p<0.05, p<0.001 Table 2: Correct Responses of Nursing Students on HIV/AIDS Mode of Transmission and Prevention by Their Year of Study (n=808). The impact of educational year on the students’ knowledge of HIV transmission and prevention is showed in Table 2. In this section, only 46.3% of first year students correctly knew that HIV is transmittable from mother to her child compared to 87.6% of those third year (p<0.001). Third year students showed better knowledge than the 1st year on the statement that says sharing injecting needles or surgical devices of seropositive person is one way of HIV transmission (p<0.001). A significant percentage of 3rd and 4th year students as compared with 1st year students (50%) knew that homosexuals are at increased risk of contracting HIV (p<0.001).

In respect of HIV prevention, more proportion of senior students than junior students reported avoiding sexual relationship with HIV/AIDS infected individuals prevents HIV transmission (p=0.001), refraining from sexual intercourse with commercial sex workers avoids HIV infection (p=0.020), penile withdrawal during sexual intercourse is not a safe method of HIV prevention (p<0.001) and sharing the same sharp materials like blade, knife and manicure is unsafe exercise (p<0.001).

Table 3 reveals the misconceptions of nursing students on HIV transmissions. Almost half of the students fallaciously considered HIV transmission via salivary secretions. The majority of respondents accurately responded that HIV cannot be transmitted through tears, sweat, kissing and sitting side by side or nearby of an infected person. About 85% of the students identified that HIV is not contagious by living together with HIV positive people. However, large proportion of students erroneously replied that HIV is transmittable through blood donation. Further misunderstandings in regard to the HIV transmission included HIV transmission through mosquito bite (71.4%) and sharing public services such as toilets and swimming pools (51.9%).

p<0.05, p<0.001 Table 4: Correct Responses on HIV/AIDS the Ways of Non-Transmission by Educational Year of the Students (n=808).

Comparison of students’ responses on HIV/AIDS non- transmission ways in the accordance to their educational study is indicated in Table 4. Third and fourth year students presented significantly more correct responses than first and second year students on the following items: HIV is spread via salivary fluid of an infected person (p=0.007), tears of an infected person (p=0.029) and via sweat of an infected person (p=0.002).

Discussion

HIV/AIDS is a well-known health threat in the recent era and it accounts for the significant number of deaths and disabilities particularly in the dynamic age groups [33]. In Turkey the incidence of registered seropositive individuals has been increasing since the emergence of the disease in 1985 [7, 8]. The contributing elements to HIV/AIDS epidemics in the nation could be multifactorial. Its tremendous growth in young population has central importance. Additionally, the strategic location of the country for international trade activities, travel and tourism activities that cause incessant mobilization of expatriates have placed the nation at greater risk for HIV epidemic. Another culprit behind the rising of HIV/AIDS may be the influx of immigrants from different countries that brought about the aggregation of commercial sex workers with associated levitation of unsafe sexual practices [4]. As the incidence of the infection is increasing in Turkey, nurses of the nation are expected to be aware of the disease and to be more supportive for patients with HIV/ AIDS.

Scholars have cited the critical impact of adequate knowledge of health professionals on delivering effective and considerate care to patients living with HIV/AIDS [34]. Therefore, determining the knowledge of Turkish undergraduate nursing students on HIV/AIDS is found to be vital to fight against the disease. It was evident in this study that students had less understanding about the high risk groups or key population for HIV/AIDS infection. Such results are similar to the findings of Walusimbi & Okonsky [35]. These unfavorable findings on risk groups strongly indicate the incompetence of students to identify the target population who are at risk of contracting HIV infection and such findings give cause for alarm.

The cohort of the students in this study scored a decent knowledge on causative agent, nature and treatment subscales. An estimated 80% of the students quoted HIV/AIDS as acquired, severe and non-curable disease. Myriads of articles also mentioned the seriousness of HIV/ AIDS in similar way [28, 36]. In the current study, almost all students correctly underlined that AIDS is caused by virus. These results were slightly higher than the research findings of some other studies Huang J, et al. [28, 37, 38]. The higher results of this research might be attributed to the combination of education provided to the students at their institutions and high HIV advertisements in the social media. Nursing students in the current study presented an average knowledge on other aspects of nature and treatment of HIV/ AIDS. However, previous studies indicated that great number of students believed the existence of vaccine for HIV/AIDS [21, 28, 39]. Students of the current research were cognizant about blood test confirmation of HIV and the nonexistence of HIV/AIDS vaccine. Consistent with those findings, literature indicated that a vast majority of nursing students were aware of the lifelong and viral nature of the disease [34, 39, 40, 41].

Findings of this study showed knowledge deficiencies in regard to the pathophysiology of HIV/AIDS compared with the previous research [10, 42]. The dearth of knowledge in this study could be stemmed from the fact that nursing program in both institutions are less likely to include in- depth lessons that cover the pathological aspects of the disease. Such findings should require a premier consideration because evidence-based and satisfactory knowledge levels are the prerequisites for nurses to execute their professional functions of caring patients with HIV/AIDS. As far as nurses play a forefront role in offering care for HIV/AIDS patients, it is imperative that they gain reasonable knowledge to ensure that safe care with minimum possible risk of contamination is provided. Increased number of studies have shown that nursing students score inadequate knowledge in regard to HIV transmission routes [28, 40, 43]. The present data indicates an overall reasonable knowledge level about the modes of HIV transmissions. Unprotected sexual contact and transfusions with contaminated blood were mentioned among the primary ways of HIV transmission. Additionally, more than 80% of the students were knowledgeable about the HIV transmission via sharing needles or syringes, infected vaginal and seminal fluids which is consistent with the findings of Akın S, et al. [21, 36, 39, 44, 45] who have found a promising knowledge score on ways of HIV transmission. On the other hand, students were not aware that homosexuals are the high risk population for HIV infection consistent to finding by Walusimbi & Okonsky [35].

The most thought-provoking finding from this survey was the fact that the students harbored unexpected misconceptions. Almost half of the samples were concerned about infection due to salivary fluids, mosquito bite, sharing public toilets and swimming pool, and sharing properties such as clothes. Such misunderstandings were echoed in other descriptive cross-sectional studies Bektas HA & Kulakac O [10, 22, 46, 47, 48]. Unlike the present findings, studies conducted by Al Jabri AA & Al-Abri JH [41, 46, 49] found tolerable false impression where only 1.2% to 10.1% of students believed that HIV is transmittable via sharing public toilets and swimming pool, and sharing official utensils with an infected person.

Misconceptions may cause unreasonable panics and adversely limit the confidence of the professionals to deliver proper nursing interventions. Nurse students are the principal professionals who are on the brink of receiving the responsibilities of educating and counseling HIV/AIDS patients on HIV transmission. According to WHO reports, there are three known universal means of HIV transmission; through sexual intercourse, through exposure to blood and blood products, and mother to her fetus or child. Shortage of understanding the ways of transmission of the infection results in exaggerated panics of contagion among healthcare workers and even patient discrimination [43]. Literature described the positive association of improved knowledge of health professionals about HIV transmission and previous formal education on HIV/AIDS [50]. Strong evidence was released from the study conducted by Catherine E Earl [47] who confirmed the positive impact of formal education on students’ capacity of understanding the disease. Additionally, one research discovered significant correlation of decent HIV/AIDS knowledge and positive attitudes of students towards patients with HIV/AIDS [51]. According to Corr, et al. [50], fear of being infected is worse if there is a knowledge scarcity in regard to causes and ways of transmission of the disease. Thus, panic of contagion while providing care for HIV/AIDS patients can be decreased by maximizing the knowledge of nurses on the transmission ways of the disease. Intensive and regular discussions on the topic of HIV/AIDS

would have positive influence on the knowledge level of the students. Therefore, in-depth education on the ways of transmission is required to enhance the confidence of the students. Likewise, an additional didactic training should be given in regard to the risk groups of HIV infection.

Knowledge in relation to HIV/AIDS prevention and precautions generally appeared quite good in this study. Students of the cohort pointed out the protective significance of keeping away from infected sharp tools, avoiding unconfirmed blood transfusion, avoiding sex with seropositive people and prostitutes. Conversely, several studies Abolfotouh MA, et al. [22, 45, 48, 52] found reduced knowledge score of students in HIV/AIDS prevention. As also reported in similar studies Bektas HA & Kulakac O [10, 36, 43, 49, 53, 54] the current sample exhibited good awareness about the protective role of condom. The intensive advertisements about preventative measures on social media and the fear of contagion could be the expected reasons for the decent knowledge on HIV prevention subdivision. Nursing students in this study appeared to be reasonably well- informed about HIV/AIDS prevention. However, that does not mean there are no areas where improvement is needed. For instance, about half of the students either did not know or did inaccurately consider that penile withdrawal method as a protective for HIV prevention. Previous studies have discussed on the critical functions of nurses in prevention of HIV transmission and promotion health [36]. Achieved findings in this study necessitate nurses to improve their knowledge level to execute their caring functions for patients living with HIV/AIDS. The role of nurse in prevention of HIV/AIDS transmission, offering care and support is huge therefore it is recommended that they should achieve a reasonable knowledge. Thus, the training program offered at the institutions should target at improving the confidence and capacity of students so that they can easily deal with HIV/AIDS infection. Educational training about HIV/AIDS in combination with case discussions is suggested to help students improve their knowledge on HIV/ADIS.

Conclusion and Recommendation

In this study, some knowledge gaps towards HIV/AIDS were discovered. It was evident in this study that students had less understanding about the high risk groups or key population for HIV/AIDS infection, on causative agent, nature and treatment subscales, and in regard to the pathophysiology of HIV/AIDS compared with the previous research findings. However, they were cognizant about confirmation of HIV diagnosis through blood test and the nonexistence of HIV/AIDS vaccine and also indicate an overall reasonable knowledge level about the modes of HIV transmissions such as unprotected sexual contact, transfusions with contaminated blood, sharing needles or syringes, infected vaginal and seminal fluids. But students missed that homosexuals are the high risk population for HIV infection. On the other hand, students showed misconceptions that HIV can be transmitted through salivary fluids, mosquito bite, sharing public toilets and swimming pool, and sharing properties such as clothes. The study also reveals a good knowledge of HIV/AIDS prevention and precautions like worth of keeping away from infected sharp tools, avoiding unconfirmed blood transfusion, avoiding sex with seropositive people and prostitutes.

As these students are among the major source of HIV/ AIDS related information for the community, they need to obtain scientific-based training about the disease so as to boost their knowledge and awareness of the disease. It can be concluded that the upgrading of knowledge towards HIV/AIDS patients can be achieved by enriching the nursing curriculum with HIV-related courses. Hence, the study suggested additional courses to be added to the curriculum that cover all aspects of HIV/AIDS that embrace cause, risk factors, diagnosis, treatment, transmission and precautions. Nursing educators are also required to establish effective approaches that would be helpful for nursing students in alleviating their fear of infection during caring people with HIV/AIDS. This can be achieved by establishing interactive group discussions or providing students with up-to-date books and journals on HIV/AIDS. Additional comprehensive studies are recommended in the future to generate representative findings in the country and to determine the core elements that influence nursing students’ HIV/AIDS knowledge level.

Limitation of The Study

Few shortfalls should be taken into account when it comes to the limitation of the study. First, as the questionnaire deals with sexuality, students might be influenced by social desirability bias in that they might express some reservations while providing their beliefs or views regarding HIV/AIDS. Second, the results gathered from the present study were assembled only from two universities which may undermine the extent to which the findings can be representative to similar nursing students of higher educational institutions. Third, the self-report nature of the question form requires a great honesty of the participants’ feedback and there was no objective scale to confirm the accuracy of some of the information delivered, hence the outcomes may elicit some degree of uncertainty.

Funding: This Study is Supported by The Research Project Unit of Erciyes University with The Project No TYL-2018- 8208.