International Journal of Africa Nursing Sciences 11 (2019) 100147

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International Journal of Africa Nursing Sciences

journal homepage: www.elsevier.com/locate/ijans

Nurses knowledge, attitudes and practices towards patients with HIV and T
AIDS in Kumasi, Ghana
⁎,1
Dorothy Serwaa Boakyea,b, , Azwihangwisi Helen Mavhandu-Mudzusic,2
a
Department of Health Studies, University of South Africa, South Africa
b
Kwame Nkrumah University of Science and Technology (KNUST) Hospital, Kumasi, Ghana
c
Department of Health Studies, University of South Africa, South Africa

A R T I C LE I N FO A B S T R A C T

Keywords: Background: Studies on knowledge, attitudes and practices among health care workers involved in HIV and AIDS
Attitudes care have often revealed the lack of knowledge about HIV and AIDS. Nurses’ knowledge may compromise the
HIV/AIDS quality of care and attitudes towards patients living with HIV/AIDS. Special nursing knowledge and skills have
Knowledge been suggested as prerequisite for taking care of patients with HIV.
Nurses
Purpose: The purpose of this study is to assess nurses’ knowledge, attitudes and practices towards patients with
Practice
HIV and AIDS in Kumasi, Ghana.
Methods: A quantitative cross-sectional study was conducted among 247 nurses at five selected health facilities
in the Kumasi Metropolis. Data was collected by means of structured self-administered questionnaire and ana-
lysed using SPSS version 23.0. Results were presented using charts and tables.
Results: Knowledge on HIV and AIDS was satisfactory but some still hold erroneous beliefs and misconception
about HIV transmission. A majority demonstrated favourable attitudes. Nurses had fears of contracting the virus,
which resulted in the display of negative attitudes by some. Their practice of universal precautions was sa-
tisfactory; however there was evidence of non-compliance among some of them.
Conclusion: The need for continuous in-service training of nurses on HIV and AIDS is a key contributing factor to
promoting knowledge, correcting a misconception, favourable attitude and improve compliance to universal
precautions and other preventive practices such as uptake of PEP.

1. Introduction million people were living with HIV and AIDS in Sub-Saharan Africa,
whereby at the end of 2014, women accounted for more than 50% of
According to the Joint United Nations Program on HIV/AIDS, since the number, 2.3 million of which were girls. Estimated new infections
the beginning of the HIV epidemic, approximately 78 million people in Sub-Saharan African were 1.4 million, which represents 70% of new
have been infected with HIV, with an approximate 35 million people infections worldwide. AIDS-related deaths account for 790,000 people
dying due to AIDS-related illnesses and an estimated 36.7 million in Sub-Saharan Africa (Sentinel Survey Report, 2015).
people living with HIV worldwide by the end of 2015 (UNAIDS, 2018). In Ghana, the prevalence rate of HIV is estimated to be 1.47%
In 2017 the number of people newly infected with HIV and the number among ages 15–49 years (UNAIDS, 2014). An estimated 250 000 of the
of people who died from AIDS-related illnesses was approximately 2.1 population living with HIV and 10 000 deaths per annum makes it a
million and 1.1 million, respectively (Foundation for AIDS Research, public health problem in Ghana (UNAIDS, 2014; Ghana AIDS
2018). Commission, 2014). The evolution of HIV infection into a chronic dis-
Sub-Saharan Africa bears the greatest burden, as it sees more than ease implicates that people with the condition will require ongoing
two thirds (69%) of all persons infected with HIV. An estimated 25.8 medical attention, antiretroviral treatment, and support from health

Abbreviations: AIDS, acquired immunodeficiency syndrome; ARV, antiretroviral; CDC, center for disease control and prevention; KAP, knowledge, attitude and
practice; KATH, Komfo Anokye teaching hospital; KNUST, Kwame Nkrumah University of science and technology; HIV, human immunodeficiency virus; PLWHA,
people living with HIV and AIDS; PEP, post-exposure prophylaxis; UNAIDS, the joint United Nations programme on HIV/AIDS; WHO, world health organization
⁎
Corresponding author at: Kwame Nkrumah University of Science and Technology Hospital, PMB, Kumasi, Ghana.
E-mail addresses: [email protected] (D.S. Boakye), [email protected] (A.H. Mavhandu-Mudzusi).
1
Postal address: KNUST Hospital, PMB, Kumasi, Ghana.
2
Postal address: Department of Health Studies, University of South Africa, City of Tswane, South Africa.

https://doi.org/10.1016/j.ijans.2019.05.001
Received 21 February 2019; Received in revised form 11 April 2019; Accepted 17 May 2019
Available online 25 May 2019
2214-1391/ © 2019 Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/BY-NC-ND/4.0/).
D.S. Boakye and A.H. Mavhandu-Mudzusi International Journal of Africa Nursing Sciences 11 (2019) 100147

workers. Hospitals in Ghana are still struggling to deal with challenges attitudes will exhibit good practices towards people living with HIV
such as uneven doctor to patient ratio in the health systems. This has and AIDS.
led to the World Health Organization (WHO) recommending tasks
shifting from doctors to nurses, midwives, and other paramedic staffs in 3. Materials and methods
the management of HIV and AIDS in 2008 (Suzan‐Monti et al.,
2015:308). The uptake of HIV/AIDS services by nurses has shown sig- 3.1. Study design and setting
nificant results. According to Iwu and Holzemer (2014:50), task shifting
to nurses has led to increased access to ART, retention in care and This study primarily applied a quantitative research approach with
improved outcomes in PLWHA. That notwithstanding, task shifting has a touch of descriptive cross-sectional study to describe and provide
contributed to increased workload and burn-out in nurses (Makhado & information about the knowledge, attitudes, and practices of nurses
Davhana-Maselesele, 2015:6). caring for HIV-infected patients in health care facilities, without at-
The nursing of HIV-positive and AIDS patients requires special skills tempting to manipulate or control the participants.
and attitudes. However, a number of studies have suggested health This study was conducted in two private health facilities (Clinic
workers including nurses hold negative attitudes towards people living [Facility A] and Medical Centre [facility B]), two public health facilities
with HIV and AIDS (Manganye, Maluleke, & Lebese, 2013:36; Ishimaru (University Hospital [facility C] and District Hospital [facility D]), and
et al., 2017:4; Wada, Smith, & Ishimaru, 2016:4). Such negative atti- a Teaching Hospital (KATH [facility E]) in the Kumasi metropolis. The
tudes come in the form of discrimination and stigma. Stigma and dis- two private health facilities selected have the longest history of HIV/
crimination undermine all efforts to reach out to people with HIV in- AIDS management services in the metropolis and have been providing
formation, HIV testing, treatment, and HIV preventive modalities to these services since 2006. The two government health facilities were
reduce their risk of infection. amongst the first health care facilities selected in the metropolis for
Amidst these negative attitudes, the nurses’ knowledge level of HIV HIV/AIDS management and had provided services to the public since
and AIDS may have an impact on the quality of services provided 2003 and administered Anti-Retroviral treatment to HIV/AIDS patients.
(Gagnon & Cator, 2015:414). The inadequate knowledge of HIV and The teaching hospital has been at the forefront of HIV/AIDS manage-
AIDS or lack thereof, are conditions associated with nurses’s demon- ment since its discovery in Ghana and was the first to introduce ARV
stration of fear, stigmatisation, and unwillingness to care for PLWHA treatment in the metropolis. All the five selected facilities run HIV
(Farotimi, Nwozichi, & Ojediran, 2015:709; Iwoi et al., 2017:10; Som, clinics, but on separate days, from 8am to 3 pm. The teaching hospital,
Bhattacherjee, Guha, Basu, & Datta, 2015:52), good knowledge on HIV/ however, runs its clinic from Monday to Fridays. The HIV clinics at the
AIDS was an important step to reducing the fears, anxiety and negative study sites including the teaching hospital do not admit or detain pa-
attitudes exhibited by nurses (Suominen et al., 2015:5; Marranzano, tients. Services provided are strictly on an outpatient basis. Patients
Ragusa, Platania, Faro, & Coniglio, 2013:4). Farotimi et al. (2015:709) whose conditions require further management with intravenous infu-
observed that poor knowledge of HIV and AIDS was a predictor of sions, blood transfusion, intravenous antibiotics, and further mon-
stigmatisation towards PLWHA. A study by Iwoi et al. (2017:5) also itoring and observation are admitted into the medical wards. Due to
noted that the lack of HIV related knowledge was linked to the de- this, registered nurses working in these wards were included in the
monstration of fear, stigmatisation, and unwillingness to care for study.
PLWHA. Lack of knowledge and misconceptions surrounding the spread The Kumasi Metropolis is the second largest city in Ghana and
of HIV has been identified by several researchers (Som et al., 2015:18) serves as the capital of the Ashanti Region (Ghana Statistical Service,
as the number one reason determining nurses’ discriminatory attitudes 2012). Kumasi is the largest cultural center and one of the biggest
towards PLWHA. In view of this, studies have suggested the need for the tourist attractions cities in Ghana. It is also situated in the middle of
inclusion of the basic aspects of HIV in the curricular of nurses’ training Ghana and therefore, serves as a transit point between all corners of the
institutions (Farotimi et al., 2015: 709). In Vienna, Lao PDR, less than country resulting in the influx of new people every day. Kumasi was
50% of the nurses and medical doctors had received formal training on selected for this study because cultural attractions and transient nature
HIV and AIDS-related issues (Vorasane et al., 2017:10). Additionally, of the city have made it a prime point for HIV/AIDS prevalence. Kumasi
the availability of resources and compliance with the standard pre- saw a sudden rise in its HIV prevalence at the rate of 3.2% as against
cautions was a positive element contributing to a positive attitude in previous rates of 2.6% in 2016, 2.7% in 2015 and 2.8% in 2014. (Ghana
nurses, such as willingness to care. Adherence to infection control Web 2018).
measures not only serves to protect nurses but also help them to render
quality care (Ishimaru et al., 2017:5). 3.2. Study population, and sample size estimation
In Ghana, although some studies were conducted on extant
knowledge, attitudes, and practices towards people living with HIV, The study population was all the registered nurses employed to
those who show any interest in the status of nurses in this regard are work in the HIV units/departments/wards in the selected health facil-
hard to come by. However, information about Ghanaian registered ities in the Kumasi metropolis and met the inclusion criteria. The in-
nurses’ knowledge, attitudes and practices (KAP) regarding HIV is clusion criteria included; participants who are qualified nurses and
needed to devise an appropriate educational program for nurses to al- have registered with the nurses and midwifery council of Ghana; par-
leviate nurses’ anxiety about caring for patients who are HIV positive ticipants who have worked in their current unit/department/ward for
and also alleviate the fear in their communities. at least three months; and participants who were between the ages of 18
and 65 years. The total number of participants recruited was propor-
2. Study hypothesis tional to the total number of registered nurses employed to work in the
HIV wards/units of the five selected health facility. The clinic (facility
It is hypothesized that; A) had a nurse population (N) of 15, the medical center (facility B) has a
population of (N = 36), the District hospital (facility C) [N = 55], the
1. Nurses HIV/AIDS related knowledge is not influenced by the University hospital (facility D) [N = 52] and the Teaching hospital
number of seminars on HIV/AIDS attended and increased years of (facility E) [N = 146] making the total population 304. The sample size
work experience. was estimated using a formula developed by Yamane in 1967.
2. Nurses with increased knowledge on HIV/AIDS will have positive
N
attitudes towards people living with HIV and AIDS. n=
1 + N (e )2
3. Nurses with increased knowledge on HIV/AIDS and favourable

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D.S. Boakye and A.H. Mavhandu-Mudzusi International Journal of Africa Nursing Sciences 11 (2019) 100147

Using a confidence level of 95%, level of precision of 5%, and po- the Delobelle et al. (2009:1072–73) study, though slight modifications
pulation size (N) of 304, the estimated sample size was purged at 247. were made in the questions. Also, the researcher ensured that care was
taken over the accurate phrasing of each question to avoid ambiguity
3.3. Sampling and pre-tested the questionnaire with 15 nurses from the medical wards
of Kumasi South Government hospital before the final study.
Within each facility, they have basically male medical and female All questionnaires were hand-delivered by the first author and the
medical wards (large rooms with beds in hospitals where patients are answered questionnaires were collected by her. Fieldworkers were not
temporary kept and nursed). However facility E had more wards. Equal used in this study. Those who satisfied the inclusion criteria, and gave
samples were drawn from each ward to form the representative sample informed consent, were given questionnaires to fill. The researcher
using the simple random sampling method. For instance, in facility A, waited for the participants to complete the questionnaires while giving
the required sample size was 14. Seven (7) participants were selected them privacy. Those participants that did not have the time to complete
from each ward. Using the manual lottery system and the attendance the questionnaires were allowed to keep them; these were collected at
register on each day as the sampling frame, the required samples were the participants’ given time. Data collection lasted for a period of two
randomly selected until the desired sample size was achieved. Any months between 10th April and 13th June 2018.
nurse who had had a chance to partake in the study was listed and
assigned a number in the lottery on subsequent visits. This was done to 3.5. Assessment of knowledge, attitude, and practices towards HIV/AIDS
avoid the repetitive selection of the same participants. Again, if a se-
lected participant failed to report to work on the day of sampling, she/ The knowledge scale was based on an instrument developed by
he was excluded from the study. Eckstein (1987) containing statements about HIV related knowledge
Co-founding factors were minimized by the; and scored as ‘True,’ ‘False’ or ‘Don’t Know.’ Correct responses were
summed on a 28-point rating scale with higher scores of (1.4–1.8) in-
1. Selection of facilities (private and Government hospitals) who use dicating higher/good knowledge levels and lower scores of (0.6–1.3)
the same policy guidelines developed by the Ghana AIDS indicating lower/poor knowledge.
Commission and Ministry of Health, Ghana. The attitude scale was based on an instrument developed by Froman
2. Selection of participants who are qualified nurses and are registered and Owen (1997), for measuring attitudes towards patients with HIV
with the Nurses and Midwives Council of Ghana. Other factors that and AIDS among nurses. The scale was scored on a five-point Likert
helped to minimized co-founders were; scale, ranging from ‘Strongly disagree,’ ‘Neither disagree nor agree,’ to
3. Majority of the participants graduated from the same nurses’ ‘Strongly agree,’ with higher scores of (2.3–3.4) indicating more
training institutions within the Metropolis and have passed through agreement.
the hands of same tutors/lecturers. The practice scale contained items that were scored as ‘yes’, ‘no’ or
4. Curriculum of study developed by the Nurses and Midwives council, ‘not applicable,’ with higher scores of (1.8–2.0) indicating good prac-
Ghana for the nurses’ training institutions in Ghana is the same. tices.
5. Often times, seminars/workshops on HIV/AIDS organized for nurses The calculated mean was derived from the summation of all the
are facilitated by the same agency. questions under knowledge, attitude and practice scales.
Ethical consideration
3.4. Data collection Ethical clearance to conduct the study was obtained from the Higher
Degrees Committee of the Department of Health Studies, University of
The instrument used in this study was a 48-item self-administered South Africa Research and Ethics. Ethical clearance was also obtained
HIV/AIDS KAP questionnaire adapted from Delobelle et al. from the Kwame Nkrumah University of Science and Technology
(2009:1072–73), which was an open-access study based on existing (KNUST) Research and Ethics Committee. Permission was sought from
instruments developed for use in nursing by Eckstein (1987) and the management and authorities of the five health care facilities that
Froman and Owen (1997). The questions on the said questionnaire were used in the study. Also, the nurses in charge of the various wards
were written in English, a language understood and spoken by all in each facility were informed before the administration of the ques-
participants. English is Ghana’s official and standard language used for tionnaires. The ethical principles of the Declaration of Helsinki were
educational instructions (Embassy, 2018). The questionnaire contained considered and followed. These were beneficence, and respect for
close-ended questions with a fixed number of responses the participants human dignity and justice (Declaration of Helsinki, 2013).
had to choose from. The questionnaire covered the various aspects Participants’ completion of the questionnaire constituted informed
under study, including the demographic characteristics, training re- consent as per the University of South Africa Ethics committee. The
ceived on aspects of HIV, knowledge, attitudes, and practices related to researcher also left her contact number with each participant to reach
the care of patients with HIV and AIDS. her where the need might arise.
The questionnaire was sub-divided into four major sections. The
first section consisted mainly of demographic content and variables 3.6. Data analysis
relating to HIV/AIDS training and care; the second section contained a
28-item HIV/AIDS knowledge scale with statements about disease In this study, the different items and responses in the questionnaire
presentation, transmission, precaution, and prevention. The third sec- were assigned codes and then analysed with Graph Pad Prism 6 and
tion contained a 10-item attitude scale and comprised of items probing SPSS Version 23. The study findings were presented in descriptive
empathic and avoidance behaviour. The fourth section consisted of a statistics. The descriptive statistics allowed the researcher to use fre-
10-item practices scale. This consisted of questions relating to universal quency, percentage, mean and standard deviations to describe the data.
precautions adherence, the requirement for and availability of post- The results were presented in frequency tables.
exposure prophylaxis (PEP) and behavior about HIV testing and re-
ferral. 4. Results
Reliability of the questionnaire was measured using the Cronbach’s
alpha coefficient. A reliability coefficient for the knowledge and atti- 4.1. Sociodemographic characteristics of study participants
tude were 0.78 and 0.66 respectively, proving the reliability and ac-
ceptability of the instrument. The reliability coefficient obtained for the Table 1 shows the socio-demographic characters of participants A
instrument in this study was similar to that (0.77 and 0.63) obtained in majority of the participants were females. The participants’ age ranged

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D.S. Boakye and A.H. Mavhandu-Mudzusi International Journal of Africa Nursing Sciences 11 (2019) 100147

Table 1 Table 2
Shows the socio-demographic characters of participants. Shows responses of participants on training they have received on HIV/AIDS.
Biographic Data Frequency (Total = 240) Percentage Variable Frequency Percentage

Age (years) Have you received any training on HIV/AIDS N = 218

< 20 8 3.7 Yes 89 40.8
20–29 99 41.3 No 129 59.2
30–39 94 39.1
Specific Areas of training on HIV/AIDS N = 128
40–49 22 9.2
VCT 22 17.2
50–59 10 4.2
PMTCT 19 14.8
60 > 7 2.9
STI 12 9.4
Gender
TB & HIV 45 35.2
Female 164 68.3
ART 22 17.2
Male 76 31.7
Couple Counseling 6 4.7
Professional Rank Other 2 1.6
Enrolled nurse 17 7.1
Frequency of workshops/seminars attended on HIV/ N = 211
Senior Enrolled Nurse 3 1.3
AIDS
Staff Nurse 107 44.6
Once in my professional practice 34 16.1
Nursing Officer 45 18.6
Monthly 4 1.9
Senior Nursing Officer 37 15.4
Quarterly 14 6.6
Principal Nursing Officer 28 11.7
Twice yearly 12 5.7
Chief Nursing Officer 3 1.3
Yearly 52 24.6
Education level Never 95 45
Certificate 38 15.8
Diploma 100 41.7 NB: VCT= Voluntary counseling and Testing; PMTCT= Prevention of mother
Degree 71 29.6 to child transmission; STI= Sexually Transmitted Disease; TB & HIV=
Masters 17 7.1 Tuberculosis & Human immunedeficiency virus; ART= Antiretroviral therapy.
Other 14 5.8

Work Environment Table 3

Public 169 70.4
Frequencies and Percentage Distribution of participants score on knowledge,
Private 68 28.3
attitude and practice.
Other 3 1.3

Professional experience (years) Variable Low High

<2 55 22.9
Knowledge 112(48.1%) 121(51.9%)
2–5 77 32.1
Attitude 105(45.3%) 127(54.7%)
6–10 60 25.0
Practice 100(44%) 128(56%)
11–15 21 8.8
15 > 27 11.2

4.4. HIV/AIDS-related knowledge of participants

from 20 to 60 years, with the most represented age group being
20–29 years. A majority of the nurses were staff nurses, and most of Table 4 shows the frequency and percentage of participants’ re-
them were trained at a level below the first degree. Their work ex- sponse to various questions on the HIV/AIDS knowledge scale: A large
perience ranged from 2 to 15 years, 2–5 years is the range with the number of participants (162, 71.1% p = < 0.0001) knew that ad-
highest frequency. The majority were working in public hospitals. A herence to antiretroviral treatment is essential to avoid the develop-
majority reported caring for HIV and AIDS patients very often. ment of drug resistance. Additionally, the majority of the respondents
(173, 83.2% p = < 0.0001) indicated that people infected with HIV
can be asymptomatic, but still infectious. Most of them (199, 83.3%
4.2. Training on HIV/AIDS p = < 0.0001) answered that HIV could not be transmitted by casual
contact, nor did most of them think that gloves were not necessary
Table 2 shows responses of participants on training they have re- when handling body fluids (204, 86.8% p = < 0.0001). More than a
ceived on HIV/AIDS: The participants who did not receive any training quarter of the respondents did not know (60, 26.3% p = < 0.0001)
in aspects of HIV and AIDS were in the majority (59.2%). Within those that HIV/AIDS is characterised by a decrease in T-4 lymphocytes,
who had received training, the majority received their training in TB causing an impaired cellular immunity. Almost half of the participants
and HIV (35.2%).When asked on how often they attended workshops/ (114, 49.6% p = < 0.0001) did not know that pulmonary TB is clas-
seminars on HIV, Majority had never attended any. Within those who sified as a WHO Clinical Stage 2 condition.
have had the privilege of attending any workshop/seminar on HIV/
AIDS, the majority had attended once in their entire professional
practice. 4.5. Attitude of participants

Table 5 shows the frequency and percentage of participants’ re-

4.3. Participants score on knowledge, attitude, and practices sponse to various questions on the HIV/AIDS Attitude scale: The ma-
jority (135, 58.4% p = < 0.0001) strongly disagreed that people with
Table 3 shows the frequencies and percentage distribution of par- HIV/AIDS only have themselves to blame. When respondents were
ticipants score on knowledge, attitude and practice: A majority of the asked whether they needed to worry about putting their family and
participants scored high for knowledge 121(51.9%), attitude friends at risk of contracting the disease when caring for a person with
127(54.7%) and practices 128 (56%). The gap between those who HIV/AIDS, most of them either strongly disagreed (71, 30.7%
scored high and those who scored low for knowledge, attitude and p = < 0.0001) or just disagreed (100, 43.3% p = < 0.0001). Many of
practices is not too great. the respondents strongly agreed (149, 64.8% p = < 0.0001) or agreed
(59, 25.7% p = < 0.0001) that patients with HIV/AIDS have the right
to the same quality of care as any other patient. Half of them responded

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D.S. Boakye and A.H. Mavhandu-Mudzusi International Journal of Africa Nursing Sciences 11 (2019) 100147

Table 4
Frequency and percentage of participants’ response to various questions on the HIV/AIDS knowledge scale.
HIV/AIDS Knowledge Scale TRUE FALSE Don't know P-value

1. HIV can be transmitted by casual contact 20(8.4) 199(83.3) 20(8.4) < 0.0001
2. HIV can been transmitted to people receiving blood transfusion 188(81.4) 31(13.4) 12(5.2) < 0.0001
3. The HI virus can easily be killed with disinfectant in the environment 10(5.2) 161(83.9) 21(10.9) < 0.0001
4. HIV is highly contagious 70(31.1) 128(56.9) 27(12.0) < 0.0001
5. HIV/AIDS is characterized by a decrease in T-4 lymphocytes, causing an impaired cellular immunity 147(64.4) 21(9.2) 60(26.3) < 0.0001
6. A person with antibody to the virus is protected against HIV/AIDS 35(15.4) 153(67.4) 39(17.2) < 0.0001
7. All pregnant women infected with HIV will have babies born with AIDS 12(5.2) 210(91.3) 8(3.5) < 0.0001
8. Gloves are not necessary when handling body fluids 25(10.6) 204(86.8) 6(2.6) < 0.0001
9. Following an accidental needle stick, there is a greater likelihood of infection with hepatitis B than with HIV/AIDS 82(35.8) 110(48.0) 37(16.2) < 0.0001
10. People infected with HIV can be asymptomatic, but still infectious 173(83.2) 26(12.5) 9(4.3) < 0.0001
11. It is possible to transmit the virus to family members of a nurse providing care for persons with HIV/AIDS, even though the 52(22.3) 158(67.8) 23(9.9) < 0.0001
nurse is not infected
12. The risk of infection with HIV after an accidental needle stick injury at the work place is high 163(69.4) 53(22.6) 19(8.1) < 0.0001
13. An individual may be infected with HIV even if he/she tests negative for HIV/AIDS antibodies 122(52.1) 68(29.1) 44(18.8) < 0.0001
14. A person can be infected with HIV for 5 years or more without getting AIDS 172(73.5) 34(14.5) 28(12.0) < 0.0001
15. The risk of occupational HIV infection and transmission among health workers is high 180(73.1) 38(15.4) 28(11.4) < 0.0001
16. Gloves and gowns are required for any contact with patients with HIV/AIDS 153(65.7) 69(29.6) 11(4.7) < 0.0001
17. One should suspect the diagnosis of HIV/AIDS in young persons who present with Kaposi’s sarcoma 143(62.7) 29(12.7) 56(24.6) < 0.0001
18. The risk of transmission of HIV during mouth to mouth resuscitation is extremely low 119(50.9) 85(36.3) 30(12.8) < 0.0001
19. To prevent accidental injury, contaminated needles should be recapped immediately after use on patients with HIV/AIDS 142(59.2) 85(35.4) 13(5.4) < 0.0001
20. Pregnant health care workers are at greater risk of contracting HIV infection at the workplace 39(16.7) 173(73.9) 22(9.4) < 0.0001
21. HIV can be easily transmitted through saliva, sweat and tears 43(18.4) 173(73.9) 18(7.7) < 0.0001
22. TB can be prevented in people living with HIV/AIDS using TB preventive therapy 104(44.6) 88(37.8) 41(17.6) < 0.0001
23. TB treatment is the same whether a patient is infected with HIV or not 142(60.9) 57(24.5) 34(14.6) < 0.0001
24. Most HIV-positive TB patients have no symptoms or signs of HIV disease 37(16.1) 147(64.2) 45(19.7) < 0.0001
25. Pulmonary TB is classified as a WHO clinical stage 2 condition 67(29.1) 49(21.3) 114(49.6) < 0.0001
26. Cotrimoxazole is not recommended for persons presenting with symptomatic HIV disease 34(14.8) 125(54.3) 71(30.9) < 0.0001
27. HIV-positive patients with a CD4-count < 200 should be assessed for antiretroviral treatment 135(58.7) 30(13.0) 65(28.3) < 0.0001
28. Adherence to antiretroviral treatment is essential to avoid the development of drug resistance 162(71.1) 35(15.4) 31(13.6) < 0.0001

that they strongly agree (116, 50.2% p = < 0.0001) that all patients A substantial number of them had incorrect knowledge about HIV
with HIV/AIDS are entitled to confidentiality, even if it puts other and AIDS management, HIV transmission and prevention/precautions.
people at risk of contracting the disease. The inadequacy of knowledge displayed by participants in this study
may be attributable to the lack of training on HIV through workshops
4.6. HIV/AIDS-related practices of participants and seminars. A majority (59.2%) of the nurses in this study admitted to
not receiving any training on HIV and AIDS, even though the nature of
Table 6 shows the frequency and percentage of response to various their job requires them to care for HIV infected patients. It was also
questions on the HIV/AIDS practice scale: Majority of the participants pitiful to note that the majority (45%) of the nurses had never attended
(194, 86.2% p = < 0.0001) practiced universal blood and body fluid any in-service training on HIV and AIDS. Of those who have had the
precautions in the workplace. Most participants (212, 92.6% privilege of attending in-service training, the majority had attended
p = < 0.0001) report having worn gloves the last time they took a once in their entire professional practice. This study agrees with the
blood sample. A majority of participants knew about the availability of suggestions of Pal, Chattopadhyay, Mandal, and Biswas (2016:130) and
PEP services at their workplace, but (25, 11.0% P = < 0.0001) would Okpala et al. (2017:547-553) regarding the need for continuous pro-
not consider starting PEP after needle pricks. A low response rate in the fessional training for nurses involved in the management and care of
affirmative was also recorded when participants were asked if they PLWHA to boost their HIV-related knowledge and competence. In-ser-
recapped needles immediately after using them (56, 24.6% vice training on HIV and AIDS has been associated with an excellent
p = < 0.0001). display and retention of HIV-related knowledge among nurses. In India,
17% of the nurses had 'excellent' knowledge, thus a knowledge score of
90%, while about 77% had a moderate level of knowledge (score of
5. Discussion
70–90%). This was after they had received in-service training a year
before the survey (Pal et al., 2016:130).
The overall knowledge of the nurses in this study was satisfactory,
Several studies have reported that nurses generally have favourable
as similar to the findings of Famoroti, Fernandes, and Chima (2013:6)
attitudes towards persons living with HIV and AIDS (Ishimaru et al.,
and Shahzadi, Kousar, Jabeen, Waqas, and Gilani (2017:162). It must
2017:5; Ledda et al., 2017:5; Zarei, Joulaei, Darabi, & Fararouei,
be noted that the study participants for Famoroti et al. (2013:6) were
2015:297). Similarly, the results of this study showed that the nurses
student nurses, but remains worth comparing. About 81% could cor-
have positive attitudes, with the majority showing greater agreement
rectly identify blood transfusion as a mode of HIV transmission. This is
with positive statements, and more disagreement with negative state-
consistent with the findings of Marranzano et al. (2013:4) and Shahzadi
ments about PLWHA. Majority of the nurses 149(64.8%) and
et al. (2017:162) that nurses have correct knowledge of HIV transmis-
144(59.5%) strongly agreed with the statements ‘patients with HIV/
sion. Nonetheless, some of the nurses sampled still hold erroneous
AIDS have the right to the same quality of care as any other patient’ and
views or misconceptions about HIV and its transmission. A significant
‘patients with HIV/AIDS should be treated with the same respect as any
proportion (22.3%) said it is possible to transmit the virus to family
other patient.’ This was quite encouraging and needs to be commended,
members of a nurse providing care for persons with HIV/AIDS, even
considering their demonstration of fear of contracting the virus and
though the nurse is not infected. This should be a cause for worry since
transmitting to their families. The findings of this study are in con-
such wrong knowledge could inform nurses’ discriminatory or unethical
gruence with a study by Ledda et al. (2017:5), that although nurses
attitudes towards patients living with the virus. A similar observation is
have fears for contracting HIV, their consciences and integrity allowed
made by Wu et al. (2016:366) and Iwoi et al. (2017:5).

5
D.S. Boakye and A.H. Mavhandu-Mudzusi International Journal of Africa Nursing Sciences 11 (2019) 100147

them to display some positive attitudes by accepting PLWHA. The fear

< 0.001

< 0.001
< 0.001
< 0.001
< 0.001
< 0.001
< 0.001
< 0.001
< 0.001
< 0.001
p-value
and anxiety is revealed in their responses to the statements ‘healthcare
workers are worried about getting HIV/AIDS from caring for a person
with HIV/AIDS in their work environment’ (60.3% showing agreement)
and ‘when caring for a person with HIV/AIDS, you need to worry about
Strongly agree

149(64.8)
putting your family and friends at risk of contracting the disease’
144(59.5)

116(50.2)
88(38.6)

52(22.4)
34(14.7)
25(10.8)
16(6.9)
18(7.8)

(18.2% showing agreement). This notwithstanding, it ought to be a

5(2.2)

cause for concern since these erroneous beliefs tend to create a feeling
of ‘not being safe,’ and therefore, lead to stigmatisation and dis-
criminatory attitudes towards PLWHA.
109(47.8)

105(45.3)
24(10.4)
59(25.7)

72(29.8)

34(14.7)
88(37.9)

49(21.2)
While nurses are mandated by the ethics of their profession to re-
17(7.3)
7(3.0)
Agree

spect the patients’ right to confidentiality and keep information ob-

tained in associates with clients to themselves (Dapaah & Senah,
2016:8), 25.1% of the nurses in this study showed disagreement with
25(10.8)

31(13.4)
47(20.3)
37(16.0)

the following statement: ‘All patients with HIV/AIDS are entitled to

Neither

11(4.7)
18(7.8)

13(5.7)
7(3.0)

9(3.7)

8(3.5)

confidentiality, even if it puts other people at risk of contracting the

disease’ (p ≤ 0. 0001). This is the indication of their tendency to dis-
close PLWHA HIV status to others. In China, 46.4% of health workers
109(47.0)
100(43.3)
59(25.5)

39(16.8)
33(14.2)
56(24.2)
30(13.0)
Disagree

disclosed a patient’s HIV status to a colleague who was not directly

11(4.8)

11(4.5)
8(3.5)

involved in the care of such a patient (Doda, Negi, Gaur, & Harsh,
2018:21-30). In Thailand, Pudpong, Srithanaviboonchai,
Chariyalertsak, Chariyalertsak, Smutraprapoot, Sirinirund,
Strongly disagree

Siraprapasiri, Ongwandee, Benjarattanaporn, Otto, and Nyblade

(2014:6) showed a third (1/3) of the samples had their HIV status
135(58.4)

disclosed to other people without their consent by health workers.

79(34.1)
71(30.7)

79(34.2)
28(12.1)
10(4.4)

22(9.5)
13(5.6)
4(1.7)

6(2.5)

Acts of discriminatory attitudes emanating from fear of contagion

were also shown in their quest to put on gowns and gloves with any
contact with PLWHA (65.7%). Similar to the findings of this study, a
3. When caring for a person with HIV/AIDS, you need to worry about putting your family and friends at risk of contracting the disease

study in KwaZulu-Natal, South Africa found 51% percent of the health

workers wore gloves for non-invasive procedures on HIV-positive pa-
tients (Famoroti et al., 2013:6). Also, a study in Thailand found 31.8%
7. Healthcare workers are worried about getting HIV/AIDS from caring for a person with HIV/AIDS in their work environment

of health workers using unnecessary personal protection measures, such

10. All patients with HIV/AIDS are entitled to confidentiality, even if it puts other people at risk of contracting the disease

as wearing double gloves when interacting with people living with HIV
(Pudpong et al. 2014:1).
Frequency and percentage of participants’ response to various questions on the HIV/AIDS Attitude scale.

Similar to other studies (Famoroti et al., 2013:6; Zarei et al.,

2015:298), this study found that a fraction of the nurses had prejudicial
2. When admitted to hospital, patients who are HIV-positive should not be put in rooms with other patients

attitudes towards PLWHA. A quarter of the population (25.5%) re-

sponded in the affirmative ‘nurses have little sympathy for people who
get HIV/AIDS from sexual promiscuity’ (p ≤ 0. 0001). The percentage
8. Health care workers are sympathetic towards the misery that people with HIV/AIDS experience

of nurses displaying prejudicial attitudes in this study was, however,

lower than that recorded in the Famoroti et al. (2013:6) (54.5%),
4. Patients with HIV/AIDS have the right to the same quality of care as any other patient

Pudpong et al. (2014:6) (42.5%) and Pal et al. (2016:130) (50–83%)

6. Patients with HIV/AIDS should be treated with the same respect as any other patient

9. Nurses have little sympathy for people who get HIV/AIDS from sexual promiscuity
5. It is especially important to work with patients with HIV/AIDS in a caring manner

study.
The practice of universal precautions by nurses was not adequate,
but it can be said to be satisfactory, as the majority responded to ad-
hering to the right practices. This is consistent with the findings of Som
et al. (2015:18). The majority (92.6%) wore gloves before examining
patients. The increased compliance with this precaution is consistent
with the report by Beckers’ Hospital Review (2016). In their report, it
1. Most people with HIV/AIDS only have themselves to blame

was stated that the precaution with the highest compliance rate was
wearing gloves (92%).
Contrary to the CDC guidelines which note that to prevent needle
stick injuries, health workers are mandated to discard used needles
immediately after use and not recap them (Wisconsin Department of
Health Service, 2018), some 25.6% of nurses in this study recapped
needles after use. The findings of this study contradict those of Chalya
et al. (2015:10) and Pal et al. (2016:130). The majority (76.7%) washed
hands before examining patients. The percentage of nurses practicing
hand washing is relatively lower than the 82% recorded in Beckers’
HIV/AIDS Attitude Scale

Hospital Review (2016) but higher than the 65% recorded in the study
by Pal et al. (2016:130). The 19% who did not wash their hands before
examining patients indicate that some nurses poorly practice universal
precaution and will, therefore, need further training on the importance
of hand washing. According to Suri and Gopaul (2018:2) as well as
Table 5

Chatrath (2017:3), mandatory hand hygiene before and after contact

with patients is the most significant procedure for preventing cross-

6
D.S. Boakye and A.H. Mavhandu-Mudzusi International Journal of Africa Nursing Sciences 11 (2019) 100147

Table 6
Frequency and percentage of responses to various questions on the HIV/AIDS practice scale.
HIV/AIDS Practice Scale Yes No N/A P-value

1. Do you encourage people to get tested and counseled for HIV/AIDS? 208(91.2) 10(4.4) 10(4.4) < 0.0001
2. Do you refer people for voluntary counseling and testing, even if these services are not available at your workplace? 180(78.9) 31(13.6) 17(7.5) < 0.0001
3. Do you know HIV/AIDS service providers or recognized organization in your area where you can refer your patients to? 158(69.3) 56(24.6) 14(6.1) < 0.0001
4. Do you practice universal blood and body fluid precautions at your workplace? 194(86.2) 13(5.8) 18(8.0) < 0.0001
5. The last time you took a blood sample, did you wear gloves? 212(92.6) 11(4.8) 6(2.6) < 0.0001
6. Do you wash your hands before examining a patient? 174(76.7) 45(19.8) 8(3.5) < 0.0001
7. Do you recap needles immediately after using them? 56(24.6) 166(72.8) 6(2.6) < 0.0001
8. Do you treat blood spills on floors or other surfaces with a disinfectant before cleaning up? 207(90.8) 14(6.1) 7(3.1) < 0.0001
9. Do you have post-exposure prophylaxis (PEP) at your workplace? 177(78.7) 21(9.3) 27(12.0) < 0.0001
10. Did you ever consider starting PEP after an occupationally acquired needle stick injury? 169(74.4) 25(11.0) 33(14.5) < 0.0001

contamination. 8. Limitation and strength

It was worrying to note that a proportion of them (21.3%) were not
aware of the availability of PEP services in their facility. Seventy-eight The study was carried out at five selected hospitals in the Kumasi
percent (78.7%) were, however, aware of the availability of PEP in their metropolis and the results may therefore only apply to similar settings.
workplace. This is consistent with the findings of Mathewos et al. This means that the results and conclusions from this study cannot be
(2013:4) (88%) and Habib, Baye, Awole, and Abebe (2018:8) (95.3%). generalised to other areas, particularly in different settings. Interviewer
The differences in the percentages may be attributed to the differences bias was minimised through the use of self-administered questionnaires.
in the samples and the formal training their participants received on This study, however, had some strength, where it seems to be the
PEP. A few (25.5%) would not consider starting PEP after exposure to first of its kind to be conducted in Ghana. Findings from this study will
HIV. Their reason for refusing to go on PEP after accidental exposure to help the Government and the Ghana AIDS Commission to devise po-
HIV was not known since the study did not make enquiries about their licies and educational strategies meant to equip nurses with the right
reasons for refusal. However, previous studies have cited side effects of prerequisite knowledge needed to dispense their duties to PLWHA in a
anti-retroviral drugs as a reason for poor uptake of PEP by nurses (Mill, way that conforms to the ethics of their profession.
Nderitu, & Richter, 2014:14; Chalya et al., 2015:12).
Funding

6. Conclusion No funding was obtained for this research.

The overall knowledge of the nurses was satisfactory; however, Ethical approval details
some had inadequate knowledge and misconceptions about HIV trans-
mission. The study also found that nurses generally have fear of con- Ethical clearance to conduct the study was obtained from the Higher
tracting the virus. Despite their increased fear of contagion, the ma- Degrees Committee of the Department of Health Studies, University of
jority displayed a positive attitude towards PLWHA. Fear of contagion South Africa Research and Ethics. Ethical clearance was also obtained
was associated with erroneous beliefs about HIV transmission, leading from the Kwame Nkrumah University of Science and Technology
to negative attitudes. Their compliance with universal precautions was (KNUST) Research and Ethics Committee.
satisfactory nonetheless, some of the participants still refused to adhere
to basic universal precautions such as hand washing. The need for Declaration of Competing Interest
continuous in-service training of nurses on HIV and AIDS is a key
contributing factor to promoting knowledge, correcting a misconcep- There are no organisations with conflict of interest related to the
tion, favourable attitude and improve compliance to universal precau- study. The authors declare that they have no financial or personal re-
tions and other preventive practices such as uptake of PEP. lationship that might have inappropriately influenced the writing of
this paper.

7. Recommendations Appendix A. Supplementary data

The Ministry of Health in Ghana ought to create opportunities for Supplementary data to this article can be found online at https://
ongoing training and development of nurses. This can be facilitated by doi.org/10.1016/j.ijans.2019.05.001.
nurse managers through in-service training that specifically addresses
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