“Bidan cantik”: Psychoeducation on HIV and AIDS to improve the service quality of midwives at Yogyakarta public health center

HIV & AIDS Review 12 (2013) 14–22

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Original research article

“Bidan cantik”: Psychoeducation on HIV and AIDS to improve the service quality of midwives at Yogyakarta public health center Andrian Liem a,b,∗ , Maria G. Adiyanti a a b

Magister of Profesional Psychology, Faculty of Psychology, University of Gadjah Mada, Yogyakarta, Indonesia Faculty of Psychology, University of Ciputra, Surabaya, Indonesia

a r t i c l e

i n f o

Article history: Received 5 December 2012 Received in revised form 7 February 2013 Accepted 8 February 2013 Keywords: Health psychology HIV and AIDS psychoeducation PMTCT SAVE Midwives

a b s t r a c t Background: Midwives play a significant role in preventing HIV transfusion from mother to child since they directly deal with prospective mothers and pregnant women. However, it is considered that the quality services of midwives have not met the maximum standards. Aim: To improve the quality service of midwives stationed at public health center through psychoeducation on HIV and AIDS based on Safer practices-Available Medication-VCT-Empowerment (SAVE) approach, referred to “BIDAN Cerdas dan Empatik (CANTIK)” program (Smart and Emphatic Midwives program). Materials and methods: Action research with quasi experiment method using non-random untreated control group design with dependent pretest and posttest samples. The participants were 24 midwives working at public health center. The research instruments used were HIV knowledge test, negative attitude towards HIV scale, emphatic and caring consultation (ECC) observation sheet, and HIV socialization. Quantitative analysis was conducted through mixed design ANOVA and qualitative analysis was conducted in the form of narrative description. Results and conclusion: BIDAN CANTIK psychoeducation program might improve the quality service of midwives at public health center. It was due to the improvement of knowledge on HIV. However, BIDAN CANTIK psychoeducation program did not significantly decrease negative attitude towards HIV and improve ECC. BIDAN CANTIK psychoeducation program was not succeeded in encouraging midwives to socialize HIV and AIDS to the patients of Health of Mother and Children Polyclinic. One of the obstacles in reducing negative attitude of midwives and in encouraging them to socialize HIV and AIDS was socio-cultural factor. © 2013 Polish AIDS Research Society. Published by Elsevier Urban & Partner Sp. z o.o. All rights reserved.

1. Introduction Women and children were vulnerable to HIV and AIDS infections [1–4]. According to WHO, without prevention effort, the risk percentage of MTCT could reach 40% [5]. Midwives play important role in preventing MTCT of HIV. The key-role of midwives was embodied in promotion of rights and reproduction health in order to prevent sexually transmitted diseases, including HIV and AIDS [5–10]. The advantage of midwives in comparison to other health profession was the high intensity of interaction between midwives and prospective mothers or pregnant women so that they might become the main source of information about health, including HIV and AIDS transmission and prevention [7,11]. Therefore, midwives

∗ Corresponding author at: UC Town, Citraland, Surabaya 60219, Indonesia. Tel.: +62 899 5084594. E-mail addresses: [email protected], [email protected] (A. Liem).

need to have deeper understanding about HIV and AIDS and constantly update their knowledge on the topic [12–14]. The fact stated differently. During initial interview (September 2011; March 2012) conducted by researcher throughout five public health centers (PHC) in Sleman District, the midwives – who mostly were diploma graduates – stated that material on HIV and AIDS had only been taught briefly to them in class. “There was only one time in class in which the lecturer taught us about sexually transmitted diseases. It was during health reproduction class.” (S, 27 years old) The finding was in accordance to the result of Focused Group Discussion (FGD) attended by midwives in Jakarta in which they felt that they were lacking in knowledge on PMTCT of HIV and AIDS and some of them even had never been taught about it [15]. The condition was a predictor of midwives’ lack of knowledge on HIV and AIDS, low self confidence in midwives to socialize HIV and AIDS issues to patients of Health of Mother and Children Polyclinic (HMCP) [7,16].

1730-1270/$ – see front matter © 2013 Polish AIDS Research Society. Published by Elsevier Urban & Partner Sp. z o.o. All rights reserved. http://dx.doi.org/10.1016/j.hivar.2013.02.001

A. Liem, M.G. Adiyanti / HIV & AIDS Review 12 (2013) 14–22

The result of discussion between the researcher and 16 midwives in Sleman District (January–April 2012) showed that those midwives tend to refuse to take care of patient that was suspected as being infected by HIV. They would instantly refer the suspected patient to Hospital due to fear of contracting the disease. “If the medical chart showed that the patient always relapsed, and then there was infection around the genital area, we instantly referred the patient to Sardjito to do a VCT. We do not know if the patient is positive, but it is better than contracting the disease. (R, 39 years old) The finding was similar to results of previous studies [17–20], which stated that knowledge and misinformation on HIV causes negative attitude and discriminative behavior by health workers towards people with HIV. Effect of knowledge and attitude altogether was 5% towards reduction of discriminative behaviors meanwhile contribution of knowledge towards attitude was 39% [21]. Knowledge on HIV is related to the attitude towards people with HIV [22]. The right knowledge on HIV and AIDS would correlate positively with emphatic attitude towards people with HIV and to preventive behavior towards exposure during practice. Midwives who understand modes of HIV transmission have low stigma towards people with HIV [23–25]. The result was in accordance to Planned Behavior Theory which stated that the decision to display certain behavior is the result of rational process that is directed towards certain purposes and following sequences of thinking [26,27]. Planned behavior or a person’s intention could be predicted through his/her attitude. Attitude is defined as positive or negative evaluation towards various aspects in social world [28]. On the other hand, midwives are also health workers who are vulnerable to various modes of HIV transmission. They carry larger risk of HIV transmission from patient to midwife during birthing process than surgeon since midwives are exposed more intensively to body fluid and they used health instrument such as syringe more often than surgeon [1,24,29–31]. Based on the result of FGD with midwives working at Prambanan PHC (April 2012), it was found that all midwives had experienced exposure to syringe, starting from the moment they open the cap of the syringe up until the moment they put the cap back on when they were finished using it. The condition above is not included in the prevention program of HIV epidemic using Abstinence–Be faithful–use Condom (ABC) approach. Therefore, an African network of religious leader infected by HIV or live with people with HIV, ANERELA+, developed and introduced a brand new approach that was more comprehensive referred to as Safer practices–Available medication–Voluntary counseling and testing–Empowerment (SAVE) in 2003. Basic concept of SAVE is to combine HIV prevention and AIDS care since ANERELA+ believes that HIV prevention can never be effective without caring and support for many AIDS cases [2,32,33]. Kurian [33] explained that S in SAVE includes the implementation of universal precaution procedures for health workers, sexual abstinence, scientific-based intervention, safe practice of blood transfusion, condom usage during intercourse, and using sterilized syringe. A is referred to medical availability such as ARV medicine for those who need it, treatment for opportunistic infections, and sufficient supply of nutrition and clean water. V is referred to voluntary and counseling testing, meanwhile E is referred to the empowerment of community through education. The education is in accordance to psychoeducation described by Supratiknya [34] as psychological education or is also commonly referred to as personality and social education. Psychoeducation is a participatory learning that encourages students to reflect on their attitude and behavior [9,35]. Psychoeducation is proven to be effective for health workers, including midwives, in improving

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knowledge on HIV and AIDS so that it may reduce negative attitude of midwives towards HIV and people with HIV, which then encourages socialization on HIV and AIDS to patients of HMCP through consultation [5,24,25,36–41]. The result of interview between researcher and midwives and physicians at PHC (September 2011; March 2012; July 2012), and tracing of official documents from Health Department and Professional Organization showed that there have not been detailed administrative procedure on what midwives and physician have to do when they are dealing with HIV suspected patients. Midwives’ knowledge on HIV and AIDS also has not had default standard. In the curriculum of diploma program of Midwifery Studies, knowledge on HIV and AIDS is only taught briefly within the material concerning Sexually Transmitted Diseases (STD) in Health Reproduction course (2nd semester) and Midwifery Pathology (4th semester). Therefore, it may be concluded that the issue studied in the research was the fact that the quality service of midwives has not met the maximum standards. It was due to midwives’ lack of knowledge on HIV and AIDS, negative attitude towards HIV and AIDS, lack of consultation skill, and lack of socialization about HIV and AIDS to patients of HMCP. The purpose of “BIDAN CANTIK” program was to improve the service quality of midwives. The improvement was indicated through improvement of knowledge on HIV and AIDS, reduction of negative attitude on HIV and AIDS, caring consultation, and socialization on HIV and AIDS towards patients of HMCP. “BIDAN CANTIK” program was an implementation of E (empowerment through education) contained in SAVE approach. Meanwhile, materials in “BIDAN CANTIK” program were an adaptation of S, A, and V. 2. Material and methods 2.1. Participants Participants in the study were 12 midwives stationed at Prambanan PHC as experiment group and 12 midwives stationed at Kalasan PHC as control group. Both PHC were in Sleman District and were chosen using non randomized method since they had more midwives than other PHC in Sleman. Inclusion criteria of participants were midwife who had graduated from Midwifery Program and worked at PHC. Meanwhile, exclusion criteria of participants were midwife who had patients, friends, or relatives who were infected with HIV; was not studying at university for undergraduate degree or higher; had not attended training or seminar about HIV and AIDS within the last year. 2.2. Research instruments 2.2.1. Knowledge on HIV and AIDS test The purpose of the test was to measure the level of knowledge on HIV and AIDS of midwives, it was developed based on previous studies [4,36,39,42–44] containing aspects which were as followed: general knowledge, causes, modes of transmission, symptoms of HIV and AIDS, treatment and medicine. There were 40 items on the test with “Right” or “Wrong” choices of answers. The result of try out on 43 respondents showed reliability score of 0.92. 2.2.2. Negative attitude scale towards HIV The purpose of the instrument was to reveal negative attitude of midwives towards HIV and people living with HIV. There are 41 items with four alternative responses starting from “very agree” to “very disagree”, and it was developed based on the previous studies [42,45,46]. The scale was divided into three parts with aspects: social isolation, discrimination, fairness, stigmatized midwives, blaming, compelling to do VCT, and comfortable contact. The result of try out on 43 respondents showed reliability score of 0.89.

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2.2.3. Emphatic and caring consultation (ECC) observation sheet ECC observation sheet was used to observe communication between midwives and their patients in HMCP during consultation [47] with indicators as followed: skill to pay attention to interlocutor and basic listening skill. 2.2.4. Socialization on HIV and AIDS observation sheet The purpose of the sheet was to observe the socialization process, which was information delivery from midwives to patients at HMCP during consultation which included: modes of transmission, general preventive measures, characteristics and symptoms of HIV and AIDS, PMTCT of HIV, treatment and medicine, VCT of HIV. Observers checked on the checklist of behavior, which contained two responses: “Not explained” and “Explained”. It was developed based on the study conducted by Gamazina et al. [38]. 2.2.5. Psychoeducation evaluation sheet It was used to evaluate the psychoeducation program given to midwives which included purpose, process, method, supporting environment, facilitator, and content [47]. The model used was reaction evaluation, which included: whether participants liked the program, whether participants felt that there were materials in the program which were irrelevant to daily life or profession. 2.2.6. Research design The study was an action research, which was a study to solve targeted group’s problem by taking advantage of collaboration between researcher and targeted group. Action research was consisted of several stages [48] which were as followed: assessment, diagnosis, designing intervention, intervention, quantitative evaluation on the output, reflection, and providing conclusion and suggestion as a repeated cycles. 2.2.7. Intervention Intervention used was quasi experimental method using non random untreated control group design with dependent pretest and posttest samples so that the effectiveness and designed alternative model of intervention were able to be proven [49] (Table 1). Intervention given was a form of HIV and AIDS psychoeducation referred to as “BIDAN CANTIK” which included scope of materials as followed: causes, modes of transmission, symptoms, prevention, HIV and AIDS care, HIV counseling, VCT, and active listening skill. It was conducted for four meeting after service hours of midwives at PHC, guided by a facilitator and co-facilitator, and was observed by observers with qualifications as followed: a. Facilitator was a VCT counselor with more than five years experience, was working at health service line of work, have experiences in providing HIV and AIDS psychoeducation for health workers.

Fig. 1. Graphic of knowledge change on EG’s participants.

b. Co-facilitator was an undergraduate or students of Master Program of Psychology with experience of providing HIV and AIDS psychoeducation. c. Observer was an undergraduate or students of Master Program of Psychology with experience of conducting observation on individual and group. 2.3. Analysis Data collected was analyzed quantitatively and qualitatively. Statistical test was also performed using mixed design ANOVA [50] and qualitative analysis was conducted in the form of narrative description of the results of observation, interview, FGD, and participants’ response on evaluation sheets. 3. Results The results were gained from one experiment group and one control group. Each group was planned to consist of 12 midwives, however in the process there were only 10 midwives in each group. One midwife in experiment group was on maternity leave and another midwife was still studying in higher Midwifery Program. Data gained from two midwives in control group was not used due to the fact that their last education was lower than others midwives. 3.1. Quantitative analysis Based on Table 2 and Figs. 1–4, it might be concluded that the initial average scores of HIV knowledge of experiment and control groups were in medium category. After attending psychoeducation program, the average scores of HIV knowledge of experiment group increased while the scores of control group remained the

Table 1 Intervention design. Group

Pretest

Treatment

Posttest

Follow-up

Experiment (EG) Control (CG)

O1 O1

X

O2 O2

O3 O3

Note. EG = midwives of Prambanan PHC; CG = midwives of Kalasan PHC; O1 = pretest: knowledge on HIV and AIDS test, negative attitude scale towards HIV, ECC observation, and socialization on HIV and AIDS observation; O2 = pretest: knowledge on HIV and AIDS test, negative attitude scale towards HIV, ECC observation, and socialization on HIV and AIDS observation; X = treatment BIDAN CANTIK; O3 = follow-up: knowledge on HIV and AIDS test, negative attitude scale towards HIV, and FGD to evaluate program. ECC observation, and socialization on HIV and AIDS observation do not repeated to minimalized patients’ uncomfortable.

Fig. 2. Graphic of knowledge change on CG’s participants.

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Table 2 Brief description of HIV knowledge and negative attitude scores per group. Experiment group

Control group

Score

TM

EM

Lv.

SD

Min

Max

Score

TM

EM

Lv.

SD

Min

Max

P1 P2 P3 S1 S2 S3

20 20 20 102.5 102.5 102.5

26.1 31.9 30.9 115.5 103 103.1

Med High High Med Med Med

3.84 3.45 3.25 21.56 16.09 16.35

20 25 25 95 72 69

32 37 35 173 116 116

P1 P2 P3 S1 S2 S3

20 20 20 102.5 102.5 102.5

23.3 21.9 22.3 121.6 119.4 119.6

Med Med Med Med Med Med

4.62 4.01 3.92 8.91 8.57 9.23

16 16 17 110 107 107

31 29 29 138 133 134

Note. P1 = Pretest score of knowledge; P2 = posttest score of knowledge; P3 = follow-up score of knowledge; S1 = pretest score of negative attitude towards HIV; S2 = posttest score of negative attitude towards HIV; S3 = follow-up score of negative attitude towards HIV; TM = theoretical mean; EM = empirical mean; Lv. = level of empirical mean (low knowledge < 14; medium knowledge = 14–27; high knowledge > 27; low negative attitude < 83; medium negative attitude = 84–123; high negative attitude > 123); SD = standard deviation; Min = minimal score; Max = maximal score.

b. There was significant difference between the average scores of knowledge on HIV of experiment and control group (F = 19,176; p < 0.0001). c. There was significant difference between the average scores of knowledge on HIV and group types (F = 28,106; p < 0.0001). The intervention which was in the form of BIDAN CANTIK psychoeducation program significantly affect the improvement of knowledge on HIV during posttest with effectiveness contribution as much as 61%.

Fig. 3. Graphic of negative attitude change on EG’s participants.

Fig. 4. Graphic of negative attitude change on CG’s participants.

same. However, the average scores of negative attitude towards HIV in both groups, both before and after the intervention, were in medium category (did not change). Pre-requirement test which included sphericity test and homogeneity test were performed before hypothesis testing using mixed ANOVA. Result of sphericity test on HIV knowledge scores was 0.459 (p > 0.05) and on negative attitude towards HIV score was 0.073 (p > 0.05). Results of homogeneity test on HIV knowledge scores before, after, and during follow up of psychoeducation were 0.435 (p > 0.05), 0.31 (p > 0.05), and 0.23 (p > 0.05). Results of homogeneity test on negative attitude towards HIV scores before, after, and during follow up of psychoeducation were 1008 (p > 0.05), 5228 (p > 0.05), and 3686 (p > 0.05). The results showed that all data was distributed normally and homogenously. Furthermore, results of hypothesis test using mixed ANOVA for HIV knowledge are: a. There was significant difference between the average scores of knowledge on HIV during pretest and posttest (F = 1098; p < 0.0001).

T-test was performed to examine the difference found using mixed ANOVA. It might be concluded that there was significant difference between the average scores during posttest and follow up of experiment and control groups (t = 5979, p < 0.001; t = 5345, p < 0.001). In the experiment group, there was significant difference between the average scores during pretest and posttest (t = −4949, p < 0.05) and during pretest and follow up (t = −4657; p < 0.05). The fact that there was no significant difference between the average scores during posttest and follow up in the experiment group showed that participants’ score improvement could be maintained up until one week after psychoeducation program. Meanwhile in the control group there was no significant difference between the average scores gained during pretest, posttest, and follow up. Furthermore, results of hypothesis test using mixed ANOVA for negative attitude toward HIV are: 1. There was no significant difference between the average scores of negative attitude towards HIV during pretest and posttest (F = 4203; p = 0.073). 2. There was significant difference between the average scores of negative attitude towards HIV of experiment group and control group (F = 5298; p = 0.034). 3. There was no significant interaction between the average scores of negative attitude towards HIV and group types (F = 2085; p = 0.139). T-test was performed to examine the difference found using mixed ANOVA with inter group variation source. It might be concluded that there was significant difference between the average scores during posttest and follow up of experiment and control groups (t = −2689, p < 0.05; t = −2779, p < 0.05). However, the decrease in the scores of negative attitude towards HIV of participants in the experiment group was not significant when the t-test was performed on the average scores during pretest and posttest (t = 1652, p > 0.05). The image of changes occurred on knowledge on HIV and negative attitude towards HIV in experiment and control groups during pretest and posttest could be viewed in Figs. 5 and 6. The result of observation on empathy of two midwives in experiment group and two midwives in control group could be viewed

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Fig. 8. Basic listening skill (ECC) change. Fig. 5. Knowledge change. 䊉 = EG;  = CG.

3.2. Qualitative analysis

Fig. 6. Negative attitude change. 䊉 = EG;  = CG.

in Figs. 7 and 8. The midwives participants in the experiment group showed improvement of empathy during consultation with patients of HMCP. However, the result of observation showed that both groups did not show HIV socialization behavior to patients of HMCP, both during pretest and posttest.

Qualitative analysis was performed on experiment group based on the result of interview, FGD, observation of psychoeducation process, and observation on participants. Qualitative analysis discussed psychological dynamic of individuals and groups. Participants in the experiment group showed changes that stood out and two midwives (Dw and Lz) observed during ECC showed meaningful progress which then was discussed qualitatively. The increase of HIV knowledge score was the most prominent in midwife Ae. The increased knowledge aspects were the modes of transmission and symptoms of HIV-AIDS. However, there were no changes at all in HIV (negative) attitude score of midwife Ae. According to midwife Ae, the purpose of the psychoeducation was already clear, easy to understand, and easy to absorb. However, Ae confessed that she was still confused on how to transfer the gained information to the patients. The decrease of HIV (negative) attitude score was the most prominent in midwives En (62 points decrease), S (31 points decrease), and Lz (23 points decrease). According to observation result, those three midwives were active in taking notes, asking, and answering questions given by the facilitator. According to midwife En and S, the training materials were related to her daily job and all of the materials were useful to them. “Before training I was very afraid with HIV or AIDS but after this program I realized that things were not scary me anymore because I know how HIV spreading deeper and more detail.” (Midwife En) “It turns out that compared to other diseases, HIV was not as scary as I thought all this time.” (Midwife S)

Fig. 7. Skill to pay attention (ECC) change.

Midwife Dw experienced the increase of HIV knowledge score by four points. However, the (negative) attitude score in midwife Dw experienced an increase by 13 points and the follow up result showed the score of 110. The increase of (negative) attitude score in midwife Dw occurred in the inspection and treatment of the HIV-infected patients. Midwife Dw agreed to place HIV-infected patients in special hospitals and not mixing them with non-HIV patients. However, during the interview it was revealed that midwife Dw thought that it was necessary to be done in order to protect the HIV-infected patients from viruses, bacterials, and germs that could worsen the patients’ condition. Moreover, the HIV-infected health workers were suggested not to handle the patients directly, so they could avoid getting infected by their patients’ illness. Midwife Lz experienced the increase of HIV knowledge score by two points. The HIV (negative) attitude score of midwife Lz was the lowest score in her group. Midwife Lz did not agree that

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HIV-infected patients have to be placed in special hospitals or separated from non-HIV patients. According to midwife Lz, if it happened, people would know which person was HIV-infected and would give stigma to patients visiting HIV special hospitals. “If we do that then it would be known who are infected. People would know and would put stigma on them [the HIV-infected patients]. If that happen they wouldn’t want to come again, and those who have never come to the special hospital wouldn’t tell about their HIV-positive status so that they could still visit regular hospitals.” (Midwife Lz) Generally, the participants felt that BIDAN CANTIK psychoeducation was interesting, very useful, and related to their profession. “Even though this is not a new topic, we still need to understand the ins and outs more deeply.” (Midwife Lz) “All this time we only knew about HIV through brief information. From this training, we got materials that were explained more clearly, more understandably . . . From this training, we knew about the wrong myths regarding HIV, how to prevent infection, post-exposure treatment, and where to ask for help in case of need.” (Midwife Rw) The participants felt that the general purpose of psychoeducation was already clear because it was conveyed from the start and according to them the purpose had been fulfilled. The personal purpose of the participants to understand HIV and AIDS more deeply had also been fulfilled. However, they felt that more concrete actions need to be taken, such as VCT or psychoeducation for villages. According to the participants, the psychoeducation process was systematic and efficient enough. However, the participants suggested that the psychoeducation should be done outside office hours. The methods used in the training, such as booklets, audiovisual, power point presentation, sharing, discussion, illustration, and role-play, could help the participants to understand the materials. Midwife Sm suggested to add more game methods to revive participants’ spirit. Regarding the environment, the participants felt uncomfortable with the room’s temperature, which was very hot despite the presence of two fans in the room. The light, which came from the window, and the circular positioning of the chairs had been deemed comfortable by the participants. Participants thought that the facilitator had a very good understanding of HIV and AIDS, could convey it clearly to the midwives, and could keep a conducive class atmosphere. For the participants, all of the materials were useful. “All of the materials were very useful because we can’t learn about HIV and AIDS piece by piece or per chapter.” (Midwife Lz) However, the most useful material according to the midwives was the modes of transmission of HIV because before the training they were very afraid of the infection. After knowing how HIV can and cannot be transmitted their fear subsided. Moreover, the most favorite material among the midwives was the topic of prevention because it related to the transmission of HIV, even more because of the nature of participants’ occupation as health workers which has a high risk of HIV infection. Some of the participants did not really like the material on ARV medicines because they thought it was difficult to memorize the types and they felt that it was not within their authority to assign medicines. The evaluation from the facilitator was that the program would be better implemented in a particular day and the midwives should get assignment letter from the head of PHC. The purpose was to ensure the midwives were in their top condition and could concentrate more on the program. Moreover, according to the facilitator, it would be better if the head of PHC gave the opening speech of the

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program so that the midwives could follow the whole process more seriously. By giving the opening speech, the head of PHC would also feel the responsibility in PMTCT of HIV. Regarding the room temperature and the behaviors of several participants like being sleepy or being busy with their cellular phones, facilitator argued that such problems were challenges for the facilitator. They must be able to maintain conducive learning atmosphere. The observers reported that all participants seemed to be enthusiastic in following the program and some participants seemed to more active compared to some others in asking and responding to questions. The high temperature of the room made participants and facilitator break into sweat, despite the presence of two electric fans. During the process, a few participants seemed sleepy while some seemed to be busy with their cellular phones. Seeing such reactions, facilitator delivered the materials in a louder voice and sometimes approached participants that seemed to be unfocused. Facilitator seemed to master the materials given and could deliver them systematically so that all materials were delivered well. According to observational data, observers did not find socialization of HIV and AIDS during the consultation process between midwives and patients in HMCP, neither before nor after the psychoeducation. From the interview result with observed midwives and program evaluation of midwives in experimental group through FGD, the reasons why the midwives did not give socialization of HIV and AIDS to HMCP’s patients were revealed. The midwives assessed that it was unnecessary to give socialization of HIV to HMCP’s patients if they did not find the symptoms or medical history of patients that lead to HIV. “We have their medical history. If there were no signs or suspicious things, I don’t think it’s necessary to give them information on HIV. If the patients came from the ‘Panti’, then we would give that information.” (Midwife Dw) Dw’s last sentence asserted that the midwives tend to socialize HIV to patients that were deemed high-risked. FGD result showed that the midwives still believed the paradigm that ‘good people’ would not get HIV. “If we know the patients and their families are good people, I don’t think we need to give them information on HIV. It feels rather weird to talk about HIV. I’m afraid they would feel insulted.” (Midwife Rw) On the other hand, the basic skill of listening and paying attention of the midwives in the experimental group experienced and increase. However, that increase was not significant compared to the control group. A sub-aspect that has been mastered well was talking with a tone that showed attention and care. Meanwhile the sub-aspect that was still weak was paying attention to the patients when they talked and giving encouraging statements. Qualitatively, it can be concluded that BIDAN CANTIK psychoeducation was useful for the midwives in improving their knowledge on HIV and AIDS. However, the midwives still felt shy and confused to channel their knowledge to HMCP’s patients. The social-culture norm also prevented the midwives from socializing HIV and AIDS to HMCP’s patients. This caused the absence of HIV and AIDS socialization behavior during observation. 4. Discussion The research aimed to test the effectiveness of BIDAN CANTIK psychoeducation in improving the public health center’s midwives’ service through knowledge/awareness on HIV, (negative) attitude to HIV, socialization of HIV and AIDS, and the emphatic consultation for the HMCP’s patients. According to the presented result, BIDAN CANTIK had significantly observed in improving knowledge on HIV

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and AIDS but not consistent in decreasing (negative) attitude of the midwives toward HIV and AIDS. Observation result showed that BIDAN CANTIK could not encourage the midwives to socialize HIV and AIDS to HMCP’s patients, as well as not significantly proved to be able to increase the midwives’ ECC. This result is aligned with previous research [40] which found that the knowledge of risk and risky behavior would not automatically create behavioral changes in health workers. According to Campbell et al. [51], the negative attitude of health workers toward HIV could not be reduced only by giving information. Three reasons why this could happen: (1) the health workers did not have confidence in their knowledge, even though that knowledge was accurate; (2) they did not know how to take action based on the possessed knowledge, in example: “I know enough about HIV and AIDS, but I have not been able to take a lot of actions regarding HIV and AIDS”. (Midwife Lz) and (3) the growing stigma within the society discouraged them in spreading information on HIV and AIDS. Moreover, in the villages there was wrong myth or information on HIV and it had rooted strongly, causing the health workers to work more strongly when delivering accurate explanation on HIV and AIDS. “If we know the patients and their families are good people, I do not think we need to give them information on HIV. It feels rather weird to talk about HIV. I am afraid they would feel insulted.” Negative attitude toward HIV was not only a cognitive process that occurred to individual, but also a socio-cultural phenomenon in community setting. That social phenomenon especially found in developing countries in which the familial cultures are still held firmly [52]. Several forming factors of stigma are cultural construction and religious misunderstanding and they are present in every community [53,54]. Kujiper [55] emphasized that attitude and behavioral change need a long term process and strong commitment. Religion and culture strongly affect the forming of faith, life values, and individual as well as social behavior. The result of Shaluhiyah’s research [56] emphasized that socio-cultural and socio-sexual factors affect teenagers’ sexual behaviors. Nyblade et al. [57] explained that midwives treating HIVinfected patients also face similar stigma from the society. Even if the midwife experienced exposure and then was contracted with HIV, then she would blame herself and internalized the stigma. Midwives and health workers were afraid to lose social status and considered to be immoral if they were infected by HIV. That fear was reflected in midwife Sm’s story on several years worth of her experience. At that time there was a woman who was almost giving birth and Sm was in charge in administration office. Several moments later, Sm found out that the woman died and was declared as HIV positive. Knowing that, Sm was really afraid that she’d contract the virus – even though she had only done intake interview and checked for blood pressure – and she prayed that she would not contract the virus. Sm did not do VCT since she did not know where to go and whom to talk about it with. Even if she had known where to do VCT, she would not have gone since she was not ready to find out about the result and people would alienate her. The result above could be explained based on Planned Behavior Theory [27], which is when a person’s behavior can be predicted from his/her behavior intention. Meanwhile, behavior intention could be affected by attitude, subjective norm, and behavioral control, in which subjective norm and external behavior control are socio-cultural constructed. Observation result showed that there was no midwife who socialized HIV to patients at HMCP even when negative attitude towards HIV had been decreased. Socialization

behavior did not show due to negative socio-cultural construction towards HIV and AIDS. The result was in accordance to the finding of Adekeye and Adeusi [17] that had been described earlier, in which knowledge and attitude altogether were only 5% affect the reduction of discriminative behavior of health workers towards people living with HIV. In the study, knowledge on HIV of participants in the control group increased significantly but their negative attitude did not decrease significantly. Meanwhile, changes in ECC occurred due to the fact that the four midwives who were observed during ECC had already had quite vast working experiences (more than 15 years experiences) so that the skill to do ECC had been mastered well. It implied to the small improvement of basic listening skill and attentive skill of midwives participants in the experiment group. On the other hand, quasi experiment with small number and non randomized subject has a few limitations on validity [49]. First is statistical conclusion validity which is threated by extraneous variance in the experimental setting, in example by room’s high temperature and inaccurate effect size estimation with an example is dichotomous HIV knowledge’s score making effect size become underestimate. Second is internal validity threated by selection used non randomized, history of subject’s experience between meeting, and maturation reflected from age range from 22 years old until 54 years old. That differences are might be affected subject’s cognition when absorbing and memorizing information. Third is construct validity threated by the weakness of check manipulation because only used qualitative description from two observer. The last, external validity threated by interaction of causal relationship with settings because the possibility of social-cultural norm in rural area is different with urban area. 5. Conclusions The results of this research showed that BIDAN CANTIK psychoeducation could help improve the service of public health center’s midwives. The service of midwives was improved through the significant increase of knowledge on HIV. However, BIDAN CANTIK was not significant in decreasing (negative) attitude toward HIV and increasing ECC. BIDAN CANTIK also could not encourage the midwives to socialize HIV and AIDS to HMC policlinic’s patients. This happened because of social-culture factor such as: (1) the midwives did not have confidence in their knowledge, even though that knowledge was accurate; (2) the midwives did not know how to take action based on the possessed knowledge; (3) the growing stigma within the society discouraged the midwives in spreading information on HIV and AIDS. Moreover, as an alternative model that had been newly implemented with small and non-randomized subjects, the effectiveness of BIDAN CANTIK cannot be generalized widely yet and has limitation on experiment validity. 6. Recommendations 6.1. For midwives of PHC BIDAN CANTIK psychoeducation can be used to improve midwives knowledge on HIV and AIDS but it is need to practice and apply it to a daily basis so they can always remember the procedure. BIDAN CANTIK can be used as an alternative procedure reference in dealing with HMCP’s patients who are suspected to be HIV-positive. 6.2. For psychologist Psychologists can help midwives in showing less negative attitude and increased empathy toward HIV orientation to them.

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6.3. For future researchers a. BIDAN CANTIK psychoeducation can reduce midwives’ negative attitude toward HIV and AIDS. However, for significant decrease, holding discussions with HIV-infected patients as well as HIVinfected and HIV-exposed health workers can be tried. b. The changes in knowledge and attitude alone are not enough to push for HIV and AIDS socialization from PHC’ midwives to HMC policlinic’s patients. It is necessary to add more materials or special sessions to create follow-up action plan that they can use with the involvement of the community or villagers. c. To increasing internal validity is necessary to conduct randomized selection and smaller range of subjects’ age to avoid the maturation. d. To increasing construct validity is necessary to conduct quantitative manipulation check, in example presenting two raters to scoring congruity between program’s blue print and what facilitator explain. e. To increasing external validity is necessary to conduct this program in various setting, in example between midwives of rural PHC and urban PHC. Conflict of interest None declared. Financial disclosure None declared. Acknowledgements Author (Andrian Liem) is grateful to Dr. M.G. Adiyanti, Psi., Prof. Koentjoro, M.B.Sc., Ph.D., Psi., Rahmat Hidayat, M.Sc., Ph.D., Dr. Ira Paramastri, Psi., Novan (PKBI DIY), Silmika Wijayanti, S.Psi., Yashinta Ardhiani P, S.Psi., Head of Puskesmas Prambanan, and Head of Puskesmas Kalasan for the support in this research. References [1] S. Burke, I. Madan, Contamination incidents among doctors and midwives: reasons for non-reporting and knowledge of risks, Occup. Med. 47 (8) (1997) 357–360. [2] J.R. Chinkonde, J. Sundby, F. Martinson, The prevention of mother-to-child HIV transmission programme in Lilongwe, Malawi: Why do so many women drop out, Reprod. Health Matt. 17 (33) (2009) 143–151. [3] F. Kasenga, Making it happen: prevention of mother to child transmission of HIV in rural Malawi, Global Health Action 3 (2010), http://dx.doi. org/10.3408/gna.v310.1882. [4] N.D. Labhardt, E. Manga, M. Ndam, J. Balo, A. Bischoff, B. Stoll, Early assessment of the implementation of a national programme for the prevention of motherto-child transmission of HIV in Cameroon and the effects of staff training: a survey in 70 rural health care facilities, Trop. Med. Int. Health 14 (3) (2009) 288–293, http://dx.doi.org/10.1111/j.1365-3156.2009.02221.x. [5] C.M. Ndikom, A. Onibokum, Knowledge and behaviour of nurse/midwives in the prevention of vertical transmission of HIV in Owerri, Imo State, Nigeria: a cross-sectional study, BMC Nurs. 6 (9) (2007), http://dx.doi.org/ 10.1186/1472-6955-6-9. [6] J.V. Lazarus, V. Rasch, J. Liljestrand, Midwifery at the crossroads in Estonia: attitudes of midwives and other key stakeholders, Acta Obstet. Gynecol. Scand. 84 (2005) 339–348. [7] S.C. Leshabari, A. Blystad, M. Paoli, K.M. Moland, HIV and infant feeding counselling: challenges faced by nurse-counsellors in northern Tanzania, Human Resour. Health 5 (18) (2007), http://dx.doi.org/10.1186/1478-4491-5-18. [8] P. Msellati, Improving mothers’ access to PMTCT programs in West Africa: a public health perspective, Soc. Sci. Med. 69 (2009) 807–812, http://dx.doi.org/10.1016/j.socscimed.2009.05.034. [9] H. Nordkvist, E. Pyykkö, Knowledge, perceptions and attitudes among midwifery students towards HIV/AIDS in Vietnam. A minor field study report (Tidak diterbitkan), Karolinska Institute, Swedia, 2008. [10] WRATZ, White Ribbon Alliance, Tanzania ‘Is It Worth it for Tanzania to Invest in Community Midwives?’. Debate Forum Report, White Ribbon Alliance for Safe Motherhood in Tanzania, Tanzania, 2006.

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