Knowledge About HIV Infection and Attitude of Nursing Staff Toward Patients With AIDS in Iran
Background. Although adequate knowledge about HIV infection and effective antitransmission measures, such as taking universal precautions in the handling of blood and other body fluids, are important factors in minimizing the risk of HIV transmission in the healthcare setting, little has been reported on the knowledge of nurses with regard to HIV infection and their attitude toward patients with AIDS in Iran. The aim of the present study was to assess these matters.
Methods. A questionnaire‐based cross‐sectional study was conducted from March to April 2003. Included were 1098 nursing staff (registered nurses, registered midwives, and auxiliary nurses) from 8 university teaching hospitals affiliated with the Shiraz University of Medical Sciences.
Results. Registered nurses and midwives had a significantly higher level of knowledge about HIV infection than did auxiliary nurses (
; 
; 
). With regard to the causative agent of AIDS, nurses holding a bachelor of science in nursing or a master of science in nursing (MSN) had a significantly higher level of knowledge than did auxiliary nurses (
; 
; 
). Women more often answered correctly that it is not possible to identify HIV‐infected patients by their appearance during the early stages of disease than did men (
; 
; 
). Although 50.7% of respondents had previously cared for patients with AIDS and 54.3% had participated in education programs on AIDS, nearly half stated that they would not want to have to care for patients with AIDS and that, if assigned to care for such a patient, they would ask to be assigned elsewhere.
Conclusions. Our finding that those who scored best on the questionnaire were midwives and single female nurses holding an MSN who had previously cared for HIV‐infected patients scored best might indicate that use of selective education campaigns is the most suitable education strategy. The effectiveness of targeted education programs on HIV/AIDS should be repeatedly evaluated in the future.
Received October 19, 2003; accepted July 14, 2004; electronically published January 6, 2006.
It has been estimated that, in the Middle East and North Africa in 2003, ∼600,000 people had HIV infections or AIDS and that ∼55,000 people had newly acquired an HIV infection during that year.1 The HIV epidemic in Iran appears to be accelerating at an alarming rate. The high number (1159) of newly diagnosed HIV infections and AIDS cases in 2001 (incidence, 1.62 cases/100,000 population) was a 3‐fold increase relative to the numbers in 2000 and 1999.2 For the first quarter of 2003, the total number of HIV‐positive patients in Iran was estimated to be 4846 (prevalence, 6.79 cases per 100,000 population). Of these, 851 (17.6%) lived in the province of Fars.3
Most HIV infections in Iran appear to be associated with injection drug use.4 A study conducted from September 1998 to April 2000 by Mansoori et al. also found that the most frequent route of HIV acquisition was injection drug use (75%), followed by heterosexual activity (16%) and blood transfusion (9%).5 Although it is likely that occupational HIV transmission among healthcare workers might occur by exposure to contaminated blood through cutaneous injuries or mucous membranes, the frequency of HIV transmission in the healthcare setting in Iran is not known. However, the internationally estimated risk of contracting HIV infection after such exposure is 0.3%.6‐8
Despite this low risk, the issue of HIV transmission in the healthcare setting has caused much public concern. Although focusing on the healthcare setting distracts society from giving proper attention to major transmission routes (unprotected sex and injection drug use), healthcare professionals have the duty of constantly reassuring the public and of educating them on how HIV infection can and cannot be contracted. More importantly, the public looks to the healthcare profession to provide an example of how to properly deal with AIDS. However, to achieve this, it is important that healthcare workers have adequate knowledge about HIV infection and about effective measures for minimizing the risk of transmission, such as taking universal precautions in the handling of blood and other body fluids.9 Although this knowledge it is of great importance, little has been reported on the knowledge of nurses with regard to HIV infection and their attitude toward patients with AIDS in Iran.
Methods
The present questionnaire‐based study used a cross‐sectional design and was conducted from March to April 2003. Different nursing groups from all 8 university teaching hospitals affiliated with the Shiraz University of Medical Sciences were included. Hospitals A‐H, which together serve as referral centers for patients in the province of Fars, had at the time of the study 298, 750, 166, 500, 52, 202, 130, and 300 beds, respectively, for a total of 2,398 beds.
So we could compare our results with those of other studies, our questionnaire was based mainly on one used by Anderson et al. in a recent study conducted in China.10 A total of 1155 nursing staff were asked to complete our questionnaire; 57 declined to participate, mostly because of a lack of time. Nevertheless, 1098 agreed to participate in our study and completed the questionnaire. It was composed of 30 questions (Table 1), including questions on demographics, the basics of HIV transmission, and attitude toward patients with AIDS. To enhance the validity of responses and to ensure clear interpretation, the questionnaire was pretested using a small random sample of participants.
Definitions of Nursing Groups
Registered nurses. After 4 years of basic education, registered nurses are trained to provide efficient patient care in all nursing specialties. Successfully trained candidates will hold a bachelor of science in nursing (BSN). These graduated nurses are capable of providing patient care on the basis of the nursing process, and they can administer medication and perform other therapeutic services aimed at promoting health. Also, they can supervise and assess nursing staff activities, diagnose problems with patient care, and contribute to the solution of such problems through their nursing skills. Furthermore, they can perform therapeutic counseling, with emphasis on developing a good rapport with patients and their families.
To be able to provide nursing services to specific care units, a nurse with a BSc may continue in an advanced program in nursing. This will, after 2 years, lead to an associate degree in nursing (with specialization in, for example, the operating room, anesthesia, or intensive care).
To attain a master of science in nursing (MSN) degree, registered nurses have to study for another 2 years. The aim of this program is to train efficient nurse practitioners and experts in the nursing sciences. Graduates are able to practice nursing at an advanced level; efficiently conduct research, management, and educational activities; and serve as a university academic staff or hospital coordinator.
Registered midwives. Registered midwives study for 4 years to attain a bachelor of science in midwifery. Graduates of this program are able to offer extensive health education and midwifery services to women of reproductive ages, thereby reducing maternal and infant mortality rates. Also, graduates provide families with teaching and counseling services on pregnancy, family planning, and having a healthy marriage, as well as on handling delivery and postpartum problems.
After 2 years of training in an advanced program in midwifery, registered midwives may apply for the master of science in midwifery program, which takes another 2 years. The aim of this program is to produce practitioners with advanced training in midwifery who can plan, coordinate, and implement maternal‐child health and midwifery services as well as train new students in this field.
Auxiliary nurses. Auxiliary nurses are paid healthcare workers with less than full professional qualification in a particular field who assist and are supervised by a professional worker. Auxiliary nurses are employed to supplement the contributions made by doctors and other highly trained personnel in promoting preventive and curative health activities. The distinction between an auxiliary nurse and a highly trained professional is that the former requires a lower level of entry, receives training that is more oriented toward practical skills, and has a lower degree of responsibility. Auxiliary nurses are supervised by registered nurses.
Statistical Analysis and Data Management
Data were entered into an electronic database using Epi Info 2000 (version 3.3; Centers for Disease Control and Prevention). To compare categorical variables, a points‐based scoring system was applied, in which 1 point was given for every correct answer and 0 points were given for false answers or withdrawals. The χ2 test, Fisher’s exact test, Student's t test, and the Duncan multiple range test were applied, as appropriate. For all tests, 
was considered to be statistically significant.
Results
Our study encompassed 1098 nursing staff, 158 (14.4%) of whom were men, and 940 (85.6%) of whom were women. Of the nursing staff, 743 were registered nurses (67.7%), 304 were auxiliary nurses (27.7%), and 51 were midwives (4.6%); their mean age (± SD) was 
years. Four hundred fifty‐eight (41.7%) of the participants were single, and 505 (46.0%) worked in surgical wards.
Most of the questionnaire respondents (97.7%) knew that the causative organism of AIDS is a virus. As the results in Table 1 show, most of the respondents also answered correctly that blood, semen, and vaginal fluid are particularly important in the transmission of HIV. However, except for blood, which was almost always correctly identified as the most important source of transmission, the respondents often overestimated the role played by all other body fluids. Specifically, 39.3% thought saliva, 28.3% thought urine, 25.7% thought tears, 22.7% thought sweat, and 19.9% thought feces to be particularly important.
At the time of the study, 50.7% of the respondents had previously been assigned to care for HIV‐infected patients. However, 45.9% of the respondents strongly agreed and 38.1% agreed that they would not want to have to care for patients with AIDS; 41.4% strongly agreed that they would ask to be assigned elsewhere if they were assigned to care for patients with AIDS, although 10.6% did not know that it is not possible to identify HIV‐infected patients by their appearance during the early stages of disease. Half of the respondents were very worried about contracting HIV infection on their jobs, and yet 25.4% agreed that HIV infection is primarily a problem for injection drug users and prostitutes but not for healthcare workers.
Of the respondents, 45.1% thought that recapping used needles is a good way to prevent HIV infection in the healthcare setting. Only 26.6% stated that there is a policy regarding postexposure management of HIV contact in their workplace, and 32.4% revealed that they had had 1 or more needle sticks during the previous 6 months. It is interesting that only 71% had received hepatitis B vaccination at the time of the study.
With respect to education programs on AIDS, 54.3% of respondents had participated in such programs (Table 1); those who had participated had higher overall scores than did those who had not (mean scores ± SD, 
vs. 
; 
) (Table 2). Our study shows that, overall, the registered nurses and midwives had a significantly higher level of knowledge than did the auxiliary nurses (
; 
; 
). Regarding the causative agent of AIDS, the nurses holding a BSN or an MSN had a significantly higher level of knowledge than did the auxiliary nurses (
; 
; 
), and the nurses holding an MSN had a significantly higher level of knowledge than did both the nurses holding a BSN and the auxiliary nurses (
; 
; 
). Women more often answered correctly that it is not possible to identify HIV‐infected patients by their appearance during the early stages of disease (
; 
; 
).
Interestingly, the respondents with a high level of knowledge about the causative agent of AIDS more frequent stated that nurses are among the groups at high risk for acquisition of HIV infection (
; 
; 
). The respondents who believed that nurses are among the groups at high risk for acquisition of HIV infection more frequently stated that it is not possible to identify HIV‐infected patients by their appearance during the early stages of disease (
; 
; 
). Also, there was a statistically significant difference between the knowledge that recapping used needles is a not good way to prevent acquisition of HIV infection in the healthcare setting (
; 
; 
).
Those respondents who were very worried about acquiring HIV infection on their jobs more often knew that reporting all needle sticks is necessary (
; 
; 
). Those who were less worried or not worried at all less often knew that it is necessary to report accidental exposure to blood or other body fluids (
; 
; 
).
Discussion
To minimize the risk of transmission, adequate knowledge about HIV infection is important. A few studies have elucidated this issue; most were conducted in Anglo‐American countries,11‐17 and some were conducted in continental European countries.18,19 The knowledge and attitudes of healthcare workers on other continents, such as Africa20‐23 and Asia,24,25 have also been studied. However, until now no study had been conducted in a Middle Eastern country—ours was the first to investigate the knowledge of nurses with regard to HIV infection and their attitude toward patients with AIDS in Iran.
Comparison of our results with those of a similar study conducted in China by Anderson et al.10 shows that Chinese healthcare workers have a greater overall knowledge (
) than do Iranian nursing staff (Table 1). Although 13.4% of the Chinese healthcare workers in that study did not know that AIDS is caused by a virus, most of them had a higher level of knowledge about preventive measures and the importance of different body fluids in HIV transmission than did the participants of the present study.
The issues of infection risk after exposure to infective material, prevention and management of injuries from sharp instruments or devices, and postexposure prophylaxis are the cornerstones of every education program on HIV transmission. However, it is interesting to observe that the Iranian nursing staff in our study, compared with the Chinese healthcare workers, more often knew that it is necessary to report all needlestick injuries (88.5% vs. 13.4%; 
) and accidental exposure to blood or other body fluids (66.8% vs. 26.8%; 
) but at the same time a high percentage of them (45.1%) thought that recapping needles is a good way to prevent acquisition of HIV infection in the healthcare setting.
Details such as these call into question the efficacy of education programs and indicate that strict staff instruction could be sufficient. However, one can speculate as to why Iranian nursing staff have this discrepancy in knowledge. One explanation might be that Iranian nurses and midwives participate in education programs less frequently than do Chinese healthcare workers. More than half of the present interrogated Iranian nursing staff had attended HIV education programs. Unfortunately, the proportion of Chinese healthcare workers attending education programs was not stated by Anderson et al.,10 leaving this possibility open for debate.
On the other hand, 46% of the Chinese study participants were physicians, and our study encompassed nursing staff alone. However, the level of knowledge about HIV infection varied little between physicians and nurses in China. As Anderson et al. concluded, little should be assumed on the basis of the nature of a person's work or medical training, and basic HIV/AIDS education should be provided to both groups.
Although 50.7% of the Iranian nursing staff had previously cared for patients with AIDS and 54.3% had participated in education programs on AIDS, there was a significant difference in attitude toward caring for patients with AIDS between our study participants and the Chinese healthcare workers. Nearly half of the Iranian nursing staff strongly agreed that they would not want to have to care for patients with AIDS and that, if assigned to care for such a patient, they would ask to be assigned elsewhere. The opposite attitude was found in China, despite the fact that both study populations stated that they were very worried about contracting HIV on their jobs (50.3% for Iran vs. 43.6% for China; 
).10 One explanation for this finding could be that knowledge might also influence the attitudes and behaviors of healthcare professionals. On the other hand, many HIV‐infected patients are injection drug users, a group that is not highly regarded by society. Therefore, this finding might have been the result of confounding. Furthermore, in a clerical society such as Iran, sexually transmitted or drug‐related diseases are often stigmatized, and dealing with patients with such diseases is often not based on rational thinking. However, if the level of knowledge demonstrated by the Iranian nursing staff were equal to that demonstrated by the Chinese healthcare workers, it would be more easy to view the influence of religion or other social factors as important.
In the end, the question still remains: Which education strategy is most suitable? Increasing the basic understanding of HIV/AIDS? Teaching the principles of infectious diseases? Stratifying target groups and then teaching according to the level of training and routine responsibilities? Or just telling personnel which behaviors are mandatory, such as reporting needlestick injuries?
Our finding that those who scored best on the questionnaire were midwives and single female nurses holding an MSN who had previously cared for HIV‐infected patients might indicate that selective education campaigns are the most suitable. We believe that such programs should be mandatory for all healthcare workers; however, education campaigns should be carefully structured and specifically tailored to a particular setting. To do this, investigation of the current level of knowledge in various settings will be necessary. Finally, the effectiveness of targeted education programs on HIV/AIDS should be repeatedly evaluated in the future.
Acknowledgment
We specially thank the respected deputy dean for research of the Shiraz University of Medical Sciences for the financial support given to this project (grant 80‐1369).
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