°'
© Longman Group UK Ltd 1990
Midwifery
o,,oo,,.,oo,oooooo.° ,,o.oo
HIV infection and c o m m u n i t y midwives: knowledge and attitudes Senga Bond and Tim J. Rhodes
Findings from two sample surveys o f c o m m u n i t y midwives in Scotland a n d E n g l a n d (N = 907) d u r i n g 1988 reveal that there is limited knowledge a b o u t m a n y aspects o f H I V infection. R e s p o n d e n t s were themselves c o n c e r n e d a b o u t their lack o f experience and knowledge as well as the availability o f resources for H I V infection. T h e r e were also substantial e d u c a t i o n a l concerns. M o r e t h a n a q u a r t e r of respondents felt t h a t they should have the right to refuse to care for H I V - i n f e c t e d patients a n d the m a j o r i t y felt that health professionals w h o are most at risk o f contact with H I V - i n f e c t e d materials should be i n f o r m e d o f patients' H I V - a n t i b o d y status w i t h o u t p a t i e n t consent. R e c o m m e n d a t i o n s are m a d e r e g a r d i n g ways o f increasing c o m m u n i t y midwives' knowledge and confidence.
INTRODUCTION From our national surveys of the implications of human immunodeficiency virus (HIV) and the acquired immunodeficiency syndrome (AIDS) for all types of community nursing staff (Bond et al, 1988; 1989), we have previously reported findings related to midwives' experience of HIV infection, how they regard their contribution to some aspects of the prevention and management of HIV infection, and preparation for their roles (Bond & Rhodes, 1990/. A number of small studies has suggested that
Senga Bond BA, MSc, PhD, RGN, Lecturer in Nursing Research, Health Care Research Unit, University of Newcastle upon Tyne, 21 Claremont Place, Newcastle upon Tyne, NE2 4AA. Tim J. Rhodes BA, Research Worker, HIV Outreach Project, Birkbeck College, University of London, 1 6 Gower Street, London, WC1 E 6DP. (Requests for offprints to SB) Manuscript accepted 6 October 1989
86
nursing staff in general may find some difficulty in their HIV-related work and that this stems from beliefs about those whose lifestyles greatly increase the risk of infection (Douglas et al, 1985; Kelly et al, 1988). The large majority of women with HIV infection are injecting drug misusers, and prostitutes are amongst the others at risk, while among men, homosexuality is prevalent (WHO, 1988). International comparisons (European Study Group, 1989) reveal that anal intercourse between heterosexuals increases the risk of transmitting the virus. A belief in the right to refuse to care for those with HIV infection points to negative attitudes (Blumenfield et al, 1987; Dring, 1987; Gordin et al, 1987; Stanford, 1988; Van Servellan et al, 1988). While affective responses to AIDS are also associated with the type of knowledge held about the illness (Gordin et al, 1987) it is possible to sustain quite bizarre notions while also having a good factual biomedical understanding of how the infection spreads (Aggleton & Homens, 1987). We therefore explored some indicators of midwives' atti-
MIDWIFERY
tudes to H I V as well as their current knowledge about the infection.
87
FINDINGS Knowledge about HIV infection
METHODS Detailed reports of the methods used are given elsewhere (Bond et al, 1988, 1989; Bond & Rhodes, 1990). Briefly, as part of a multiple choice postal questionnaire, items were included to test knowledge, and other questions sought an understanding of beliefs about H I V and those who have H I V infection. Questions were asked about the right to refuse care, passing on information about H I V status, as well as concerns about H I V infection. While the study included different types of community nursing staff, only findings from the sample of c o m m u n i t y midwives are reported here. A response rate of 83% was achieved giving a sample size of 907 community midwives who were not in managerial grades. D a t a were analysed using S P S S X (SPSS Inc., 1986). Comparisons between nominal variables were made using chi-square tests while knowledge scores were compared using t-tests. Nonresponse to specific questions causes a change in the denominator used to calculate responses. Figures provided in tables represent the n u m b e r of valid responses.
O f the 10 knowledge questions asked (Table 1) respondents were most likely to know that blood for transfusion was routinely tested for H I V antibodies and that application of the procedures to protect against infection with Hepatitis B is also appropriate for avoiding H I V infection. Community midwives were least likely to be knowledgeable about more recent clinical facts associated with the development and transmission of H I V infection and greatest uncertainty was expressed over the development of encephalopathy. It m a y have been the term itself which caused the uncertainty. The mean n u m b e r of correct responses was 5.6 (standard deviation 1.8) indicating a limited range of knowledge for m a n y respondents. Those who had experience of HIV-infeeted patients and those who had received in-service education about H I V infection scored higher (6.1 compared with 5.6, p < 0.04; and 5.9 compared with 5.1, p < 0 . 0 0 1 respectively). Those who had experience of HIV-infected patients were more likely to know that newborn babies who show H I V antibodies m a y become H I V antibody negative. Those who had had in-service
Table 1 C o m m u n i t y m i d w i v e s " k n o w l e d g e a b o u t H I V i n f e c t i o n and A I D S
The H IV blood test in routine use detects the presence of antibodies to the virus that can cause AIDS After H IV infection it can take three months until antibodies can be detected in the blood Procedures for avoiding Hepatitis B infection are also appropriate for avoiding HIV infection Spills of HIV infected material can be inactivated by simple disinfectants such as household bleach The risk of acquiring HIV infection after a needlestick contaminated by HIV infected blood is less than 1% New born infants w h o initially test H IV positive may, over time, become HIV negative HIV can be transmitted in breast milk All blood intended for transfusion in the United Kingdom is tested for HIV antibodies Over 75% of people with HIV infection have developed AIDS within five years of becoming H IV antibody positive Encephalopathy is more likely to occur in people who are H IV positive than people who are H IV negative Note: * Denotes the correct response. Number of valid responses ranged from 889 to 901.
True
False
Uncertain
%
%
%
72* 76*
13 10
15 14
85"
7
8
58*
20
22
38* 25* 60* 92*
31 42 12 2
31 33 28 6
22
38*
4O
35*
10
55
88
MIDWIFERY
education about H I V infection were more likely to know that it can take up to three months for H I V antibodies to show, that procedures for avoiding Hepatitis B are appropriate for avoiding infection, that household bleach inactivates H I V , that risk of infection from an HIV-infected needlestick injury is less than 1% and that H I V can be transmitted in breast milk.
Opinions about the right to refuse care W h e n asked whether they should have the right to refuse care for certain patient groups, there was a clear gradient of opinion (Table 2). More community midwives considered that they should have the right to refuse to care for patients who have A I D S and H I V infection, than for those whose lifestyles put them at risk of infection. Significantly fewer respondents were of this opinion regarding people with haemophilia who have been exposed to risks of H I V infection through the administration of infected blood products rather than through their particular lifestyles. However, there were significant differences in opinion about the right to refuse to care between those who were concerned about personal infection with H I V and those not concerned, as shown in Table 3. Differences in the same direction were found between those expressing a wish for more information about occupational risks of H I V infection and those not wishing more information. There were no differences in opinion
Table 2 O p i n i o n s a b o u t t h e r i g h t t o refuse c a r e t o s o m e types of patients
Patient group
People with AIDS People with HIV infection Bi-sexual men Injecting drug users Haemophiliacs
Should be Uncertain able to about right refuse to refuse
Should not be able to refuse
% 30
% 13
% 57
25 20
13 14
62 66
18 8
13 9
69 83
Number of valid responses ranged from 859-896.
about the right to refuse to provide care between those who had had in-service education about H I V infection and those who had not, or between those with experience of HIV-infected patients and those who had not encountered patients with H I V .
Opinions about confidentiality Just over one third of respondents indicated that they were concerned abofit confidentiality over patients' H I V - a n t i b o d y status and only 40% had read what they considered to be an adequate policy statement or guidelines about confidentiality. Almost half (44%) of respondents did not know whether they would be informed if patients of theirs were known to be H I V positive while one third were of the opinion that they would always be informed. However, 97% of respondents thought that they should be informed of patients' H I V - a n t i b o d y status of w h o m 77% thought that this should be the case even without patient consent and only 2% thought that they should not be informed at all. Again there was a clear gradient of opinion such that it was deemed appropriate by a majority of respondents that those professionals who m a y be involved in providing care of a physical nature to patients should be informed about H I V - a n t i b o d y status w i t h o u t regard for patient consent (Table 4). Examination of Table 4 shows that a larger proportion of respondents felt that patient consent should be taken into consideration regarding passing on information about their H I V - a n t i b o d y status to those types of nursing staff less likely to be involved in carrying out physically intimate personal tasks and associates of patients who are not health professionals. This suggests that patient consent is viewed as secondary to midwives' own concerns and the perceived concerns of other health professionals about working with infected patients. Similarly, while 94% of respondents considered that the sexual partners of patients positive for H I V infection should be informed of this, 51% of respondents thought that this should be without patient consent. This figure is lower than for m a n y health professionals at minimal risk of infection while risk of infection is far greater for sexual partners.
MIDWIFERY
89
Table 3 M i d w i v e s w h o are and are n o t concerned a b o u t risk of personal infection w i t h H I V and opinions t h a t t h e y should have t h e right to refuse care
Patient group
Midwives concerned abour risk of infection
Midwives not concerned about risk of infection
P value
People with AIDS People with H IV infection Bi-sexual men Injecting drug users Haemophiliacs
N 561 564 540 561 557
N 316 31 7 307 314 310
© Longman Group UK Ltd 1990
Midwifery
o,,oo,,.,oo,oooooo.° ,,o.oo
HIV infection and c o m m u n i t y midwives: knowledge and attitudes Senga Bond and Tim J. Rhodes
Findings from two sample surveys o f c o m m u n i t y midwives in Scotland a n d E n g l a n d (N = 907) d u r i n g 1988 reveal that there is limited knowledge a b o u t m a n y aspects o f H I V infection. R e s p o n d e n t s were themselves c o n c e r n e d a b o u t their lack o f experience and knowledge as well as the availability o f resources for H I V infection. T h e r e were also substantial e d u c a t i o n a l concerns. M o r e t h a n a q u a r t e r of respondents felt t h a t they should have the right to refuse to care for H I V - i n f e c t e d patients a n d the m a j o r i t y felt that health professionals w h o are most at risk o f contact with H I V - i n f e c t e d materials should be i n f o r m e d o f patients' H I V - a n t i b o d y status w i t h o u t p a t i e n t consent. R e c o m m e n d a t i o n s are m a d e r e g a r d i n g ways o f increasing c o m m u n i t y midwives' knowledge and confidence.
INTRODUCTION From our national surveys of the implications of human immunodeficiency virus (HIV) and the acquired immunodeficiency syndrome (AIDS) for all types of community nursing staff (Bond et al, 1988; 1989), we have previously reported findings related to midwives' experience of HIV infection, how they regard their contribution to some aspects of the prevention and management of HIV infection, and preparation for their roles (Bond & Rhodes, 1990/. A number of small studies has suggested that
Senga Bond BA, MSc, PhD, RGN, Lecturer in Nursing Research, Health Care Research Unit, University of Newcastle upon Tyne, 21 Claremont Place, Newcastle upon Tyne, NE2 4AA. Tim J. Rhodes BA, Research Worker, HIV Outreach Project, Birkbeck College, University of London, 1 6 Gower Street, London, WC1 E 6DP. (Requests for offprints to SB) Manuscript accepted 6 October 1989
86
nursing staff in general may find some difficulty in their HIV-related work and that this stems from beliefs about those whose lifestyles greatly increase the risk of infection (Douglas et al, 1985; Kelly et al, 1988). The large majority of women with HIV infection are injecting drug misusers, and prostitutes are amongst the others at risk, while among men, homosexuality is prevalent (WHO, 1988). International comparisons (European Study Group, 1989) reveal that anal intercourse between heterosexuals increases the risk of transmitting the virus. A belief in the right to refuse to care for those with HIV infection points to negative attitudes (Blumenfield et al, 1987; Dring, 1987; Gordin et al, 1987; Stanford, 1988; Van Servellan et al, 1988). While affective responses to AIDS are also associated with the type of knowledge held about the illness (Gordin et al, 1987) it is possible to sustain quite bizarre notions while also having a good factual biomedical understanding of how the infection spreads (Aggleton & Homens, 1987). We therefore explored some indicators of midwives' atti-
MIDWIFERY
tudes to H I V as well as their current knowledge about the infection.
87
FINDINGS Knowledge about HIV infection
METHODS Detailed reports of the methods used are given elsewhere (Bond et al, 1988, 1989; Bond & Rhodes, 1990). Briefly, as part of a multiple choice postal questionnaire, items were included to test knowledge, and other questions sought an understanding of beliefs about H I V and those who have H I V infection. Questions were asked about the right to refuse care, passing on information about H I V status, as well as concerns about H I V infection. While the study included different types of community nursing staff, only findings from the sample of c o m m u n i t y midwives are reported here. A response rate of 83% was achieved giving a sample size of 907 community midwives who were not in managerial grades. D a t a were analysed using S P S S X (SPSS Inc., 1986). Comparisons between nominal variables were made using chi-square tests while knowledge scores were compared using t-tests. Nonresponse to specific questions causes a change in the denominator used to calculate responses. Figures provided in tables represent the n u m b e r of valid responses.
O f the 10 knowledge questions asked (Table 1) respondents were most likely to know that blood for transfusion was routinely tested for H I V antibodies and that application of the procedures to protect against infection with Hepatitis B is also appropriate for avoiding H I V infection. Community midwives were least likely to be knowledgeable about more recent clinical facts associated with the development and transmission of H I V infection and greatest uncertainty was expressed over the development of encephalopathy. It m a y have been the term itself which caused the uncertainty. The mean n u m b e r of correct responses was 5.6 (standard deviation 1.8) indicating a limited range of knowledge for m a n y respondents. Those who had experience of HIV-infeeted patients and those who had received in-service education about H I V infection scored higher (6.1 compared with 5.6, p < 0.04; and 5.9 compared with 5.1, p < 0 . 0 0 1 respectively). Those who had experience of HIV-infected patients were more likely to know that newborn babies who show H I V antibodies m a y become H I V antibody negative. Those who had had in-service
Table 1 C o m m u n i t y m i d w i v e s " k n o w l e d g e a b o u t H I V i n f e c t i o n and A I D S
The H IV blood test in routine use detects the presence of antibodies to the virus that can cause AIDS After H IV infection it can take three months until antibodies can be detected in the blood Procedures for avoiding Hepatitis B infection are also appropriate for avoiding HIV infection Spills of HIV infected material can be inactivated by simple disinfectants such as household bleach The risk of acquiring HIV infection after a needlestick contaminated by HIV infected blood is less than 1% New born infants w h o initially test H IV positive may, over time, become HIV negative HIV can be transmitted in breast milk All blood intended for transfusion in the United Kingdom is tested for HIV antibodies Over 75% of people with HIV infection have developed AIDS within five years of becoming H IV antibody positive Encephalopathy is more likely to occur in people who are H IV positive than people who are H IV negative Note: * Denotes the correct response. Number of valid responses ranged from 889 to 901.
True
False
Uncertain
%
%
%
72* 76*
13 10
15 14
85"
7
8
58*
20
22
38* 25* 60* 92*
31 42 12 2
31 33 28 6
22
38*
4O
35*
10
55
88
MIDWIFERY
education about H I V infection were more likely to know that it can take up to three months for H I V antibodies to show, that procedures for avoiding Hepatitis B are appropriate for avoiding infection, that household bleach inactivates H I V , that risk of infection from an HIV-infected needlestick injury is less than 1% and that H I V can be transmitted in breast milk.
Opinions about the right to refuse care W h e n asked whether they should have the right to refuse care for certain patient groups, there was a clear gradient of opinion (Table 2). More community midwives considered that they should have the right to refuse to care for patients who have A I D S and H I V infection, than for those whose lifestyles put them at risk of infection. Significantly fewer respondents were of this opinion regarding people with haemophilia who have been exposed to risks of H I V infection through the administration of infected blood products rather than through their particular lifestyles. However, there were significant differences in opinion about the right to refuse to care between those who were concerned about personal infection with H I V and those not concerned, as shown in Table 3. Differences in the same direction were found between those expressing a wish for more information about occupational risks of H I V infection and those not wishing more information. There were no differences in opinion
Table 2 O p i n i o n s a b o u t t h e r i g h t t o refuse c a r e t o s o m e types of patients
Patient group
People with AIDS People with HIV infection Bi-sexual men Injecting drug users Haemophiliacs
Should be Uncertain able to about right refuse to refuse
Should not be able to refuse
% 30
% 13
% 57
25 20
13 14
62 66
18 8
13 9
69 83
Number of valid responses ranged from 859-896.
about the right to refuse to provide care between those who had had in-service education about H I V infection and those who had not, or between those with experience of HIV-infected patients and those who had not encountered patients with H I V .
Opinions about confidentiality Just over one third of respondents indicated that they were concerned abofit confidentiality over patients' H I V - a n t i b o d y status and only 40% had read what they considered to be an adequate policy statement or guidelines about confidentiality. Almost half (44%) of respondents did not know whether they would be informed if patients of theirs were known to be H I V positive while one third were of the opinion that they would always be informed. However, 97% of respondents thought that they should be informed of patients' H I V - a n t i b o d y status of w h o m 77% thought that this should be the case even without patient consent and only 2% thought that they should not be informed at all. Again there was a clear gradient of opinion such that it was deemed appropriate by a majority of respondents that those professionals who m a y be involved in providing care of a physical nature to patients should be informed about H I V - a n t i b o d y status w i t h o u t regard for patient consent (Table 4). Examination of Table 4 shows that a larger proportion of respondents felt that patient consent should be taken into consideration regarding passing on information about their H I V - a n t i b o d y status to those types of nursing staff less likely to be involved in carrying out physically intimate personal tasks and associates of patients who are not health professionals. This suggests that patient consent is viewed as secondary to midwives' own concerns and the perceived concerns of other health professionals about working with infected patients. Similarly, while 94% of respondents considered that the sexual partners of patients positive for H I V infection should be informed of this, 51% of respondents thought that this should be without patient consent. This figure is lower than for m a n y health professionals at minimal risk of infection while risk of infection is far greater for sexual partners.
MIDWIFERY
89
Table 3 M i d w i v e s w h o are and are n o t concerned a b o u t risk of personal infection w i t h H I V and opinions t h a t t h e y should have t h e right to refuse care
Patient group
Midwives concerned abour risk of infection
Midwives not concerned about risk of infection
P value
People with AIDS People with H IV infection Bi-sexual men Injecting drug users Haemophiliacs
N 561 564 540 561 557
N 316 31 7 307 314 310
