The impact of an intervention to change health workers' HIV/AIDS attitudes and knowledge in Nigeria

Abstract

The aim of the study was to improve health workers' skills and confidence in dealing with patients with HIV disease and increase attention to patients' human rights.

A longitudinal controlled trial was carried out in which one Nigerian state served as the intervention site and the adjacent state served as the control site for an intervention and dissemination of training in clinical management, health education, and attitudinal change toward patients with HIV disease. The intervention group n = 1072, control group n = 480.

Following initial questionnaire-defining focus groups, nurses, laboratory technologists and physicians in all base hospitals in the intervention state were trained by influential role models who attended the initial training. Data were collected in all sites pre-training and 1 y later. Hierarchical multiple regression analysis controlling for baseline data, and orthogonal factor analysis to define scales were used.

Data showed significant positive changes after 1 y in the intervention group on perception of population risk assessment, attitudes and beliefs about people with HIV disease, less fear and more sympathy for and responsibility toward HIV patients, and an increase in self-perceived clinical skills. There was increased willingness to treat and teach colleagues about people with HIV. Clinician fear and discrimination were significantly reduced, and the climate of fear that was associated with HIV was replaced with a professional concern. There was increased understanding of appropriate psychosocial, clinical and human rights issues associated with HIV treatment and prevention.

This intervention, targeting health workers in an entire state and using HIV/AIDS information, role modeling, diffusion of training and discussions of discrimination and human rights, significantly affected the perception of risk groups and behaviors, perceived skills in treatment and counseling, reduced fears and increased concern for people with HIV disease, and improved the climate of treatment and prevention of HIV disease compared with a control state. Public Health (2002) 116, 106–112

Introduction

While the HIV epidemic has been slower to impact Nigeria than many other African countries, recent evidence suggests that HIV prevalence is high and geographically and socially widely distributed. Esu-Williams et al¹ report that in 2300 samples from five states in Nigeria, HIV-1 appears in over 60% of commercial sex workers (CSWs), 8% of blood donors in some states, with male clients of CSWs, truck drivers, and STD patients having respectively 8%, 9%, and 21% seroprevalence. Their data suggest a rural HIV-1 and 2 epidemic.

The recent high rate of spread of HIV in Nigeria has meant that health workers have had to be educated about a disease that is not only clinically different but also requires different ways of dealing with sharp instruments. Perhaps most important, the epidemic of fear associated with HIV/AIDS worldwide has been as apparent in Nigeria as elsewhere. Adegboye² reports on AIDS patients being the subject of neglect and being objects of exhibition, with only a third of physicians and a quarter of nurses saying they would take care of an AIDS patient. Adelekan et al³ replicated these findings in a different state in Nigeria 1 y later. Data from Akande and Ross⁴ on AIDS fears in Nigeria confirm that fears of infection and illness account for a substantial proportion of fears of AIDS.

A recent study by Olubuyide⁵ in Ibadan demonstrated that 64% of doctors believed that they should be allowed to decide for themselves whether to treat the HIV-infected patient, and half believed that refusing to take care of such a patient was not unethical. Such responses must be located in the context of infection control practices: Odujinrin and Adegoke⁶ noted that while almost all respondents in their survey of health workers in Lagos claimed to be more careful in their blood handling practices since learning of AIDS, 69% wore gloves for all procedures and 29% sometimes. Nevertheless, between a third and a half did not wear gloves for cleaning up bloodstained materials and nursing procedures. Olubuyide and Olawuyi⁷ surveyed 149 residents to estimate exposure to blood and body fluids over 1 y in Ibadan. Over 90% reported one or more needlestick or sharp instrument exposures (with a mean of 7.7), with three-quarters using universal precautions half the time or less.

Compared with the United States, Essien et al⁸ found that Nigerian health workers' infection control practices were determined by whether they knew the patient was HIV infected. Differences between the two countries occurred where the patient was not known to be infected, but there were no differences with a known HIV-infected patient. Infection control was related to precautions in the United States but not Nigeria. Essien et al⁹ reported HIV-related infection control practices in Nigeria were more likely to be based on peer ridicule as a means of enforcing group norms, while peer enforcement of norms was significantly lower in the US. However, they also noted that availability of disposable equipment in Nigeria was low.

The low acceptance of HIV/AIDS patients in Nigeria described by Adegboye² and Adelekan et al³ has implications for treatment, prevention, and human rights. It leads us to propose an intervention to increase acceptance of HIV/AIDS patients and to improve health workers' skills and confidence in dealing with HIV/AIDS patients. We report on a study which compared health workers in intervention and control samples at baseline and post-intervention, using one state as an intervention and the adjacent state as a control.