HIV infection and community midwives: Knowledge and attitudes

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Midwifery

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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

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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-

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tudes to H I V as well as their current knowledge about the infection.

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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

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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.

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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

<0.001 < 0.001 <0.003 < 0.002 < 0.02

% 37 31 22 21 9

Concerns of c o m m u n i t y m i d w i f e r y staff about HIV infection O f the items offered, by far the largest proportion of respondents indicated that they were concerned about their lack of experience with H I V infection (Table 5). Significantly fewer of those who had encountered patients with H I V int~ction were concerned about this (65% compared with 86%, p < 0.001). Two thirds of respondents were concerned about the availability of resources to deal with H I V infection, while half indicated that they were concerned about the availability of professional support networks. It is

% 18 15 16 13 7

noteworthy that just over 40% of those who had read what they judged to be adequate policies about, for example, terminal care for patients with AIDS and providing counselling for those worried about H I V infections were concerned about resources compared with over 70% of those who had either not read policies or had read what they considered to be inadequate policies. A number of educational issues featured in the list and tile proportions who indicated concern revealed that respondents appreciated their lack of knowledge as demonstrated in the knowledge

Table 4 V i e w s of w h o should be i n f o r m e d of patient's H I V - a n t i b o d y status

Patient's own G P Hospital consultants Community midwives Yourself Hospital nursing staff Dentists District nurses Practice nurses Own G P's partners Health visitors Sexual partners Community psychiatric nurses School nurses School teachers Close relatives Practice receptionists and secretaries Employers Close friends

Should not be informed

Informed without the individual's consent

Informed only with the individual's consent

Uncertain

% 2 2 2 1 2 2 2 3 4 3 1 8 13 24 11 66 38 24

% 83 82 79 77 77 74 74 65 64 59 5~1 44 42 15 13 5 4 4

% 14 14 18 20 18 21 20 24 26 31 43 32 27 39 66 17 39 58

% 1 2 1 2 3 3 4 8 6 7 5 16 18 22 10 12 19 14

Number of valid responses ranged from 868 to 895.

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Table 5 C o n c e r n s associated w i t h HIM i n f e c t i o n and A I D S

Nature of concern Lack of experience Availability of resources Risk of personal infection Insufficient in-service training Keeping up to date with developments Lack of professional support networks Reliability of information Passing infection on to family Lack of personal knowledge Lack of confidentiality Passing infection on to other clients Uneasiness in discussing misuse of injecting drugs Uneasiness in discussing safer sex Receiving too much information

Number of Percentage respondents concerned 895 877 891

84 66 64

888

63

884

60

867 883 876 882 859

51 49 48 43 36

873

34

868

20

876

10

875

8

questions reported above, as well as m a n y feeling that the in-service education being provided was insufficient. While almost half of those who had had HIV-related in-service education were of the opinion that it was insufficient, the figure for those w h o had received none was 85%. It was reassuring that, despite the great deal of media attention given to H I V infection during the months preceding the study, only a small minority t~lt that they had received too m u c h information. While risk of infection with H I V is not only from potential exposure at work, that 64% of respondents indicated concern about personal infection while no fewer than one third feared that they would pass the infection on to patients or clients suggests that there remains a substantial proportion of respondents who hold misapprehensions about the transmissibility of HIV_

DISCUSSION T h e findings presented in this paper are consistent with, and add to those in our previous paper (Bond & Rhodes, 1990). T h a t most of the respondents indicated concern over their lack ofex-

perience reflects the current low level of experience of patients with H I V infection per se, and the small n u m b e r of patients that rank and file staff with experience had encountered. Thus the lack of confidence we found a m o n g community nursing staff is again reflected in the data reported here. T h e limited knowledge demonstrated by m a n y respondents gives cause for concern. H a l f of the respondents were concerned about their knowledge of H I V infection and almost two thirds were concerned about keeping up to date with trends and developments. As so few thought that they had received too m u c h information, it is suggested that this workforce would be receptive to education about H I V infection. T h e least well answered questions, relating to issues of mothers and babies, were in topics where only recently had certainty been expressed in the findings of research (European Collaborative Study, 1988; Italian Multicentre Study, 1988; Semprini et al, 1988; M u n y a k h o , 1988; Mortimer & Cooke, 1988; Logan et al, 1988). Indeed the need for caution in the interpretation of findings about H I V infection is stressed in the most recent report of the Social Services Committee (1989) on A I D S which says ' . . . no sooner has a m a p of the disease been drawn but it is out of date'. This applies not only to its clinical features but also to the important topic for midwives of the inactivation of HIV-infected material (Cooke, 1989). T h a t so m a n y respondents were concerned about the reliability of the information provided to them is likely to be as m u c h a reflection of uncertain and changing knowledge about H I V infection as the quality of the information p r o vided. However, it points to the potential value of regular and authoritative bulletins for staff which summarise recent findings and, where appropriate, point out their implications for practice. T h a t 4 in every 10 midwives considered that they should have the right, or were uncertain about having the right, to refuse to care for patients with AIDS, indicates a substantial body of opinion at odds with the Code of Professional Conduct issued by the United K i n g d o m Central Council for Nursing, Midwifery and Health Visiting ( U K C C , 1988). However, it was only

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towards those with the illness itself that negative opinions were expressed. C o m m u n i t y midwives m a y not have a great deal of contact with bisexual men, yet one third of them considered that they should have or were u n c e r t a i n a b o u t whether they should have the right to refuse them care. T h e similar findings a b o u t injecting drug users are indicative of negative personal beliefs about lifestyles which put people at risk of H I V infection. I n this respect midwives were no different from other kinds of c o m m u n i t y nursing staff (Bond et al, 1988, 1989). T h e association between opinions a b o u t the right to refuse care, concern a b o u t infection With H I V and concern a b o u t lack of knowledge indicates the powerful role that fear may be playing in influencing personal beliefs a b o u t certain p a t i e n t groups and about dealing with infected patients. C o n c e r n by one third of the midwifery respondents about transmitting the virus to other clients is a further reflection of the influence of irrational beliefs a b o u t the virus. T h e finding- that so m a n y respondents felt that they, and others in physical contact with patients, should be informed a b o u t H I V - a n t i body status was c o m m o n to all kinds of c o m m u n ity nursing staff. Thus, while there are clinical implications for HIV-positive p r e g n a n t w o m e n a n d their u n b o r n children regarding possible term i n a t i o n of pregnancy, this need to know is likely to be a further manifestation of midwives' concern for their own safety. It is also a further disregard of the U K C C ( U K C C , 1988) guidelines regarding the rights of patients. I n our previous paper (Bond & Rhodes, 1990) we drew attention to the fact that m a n y midwives had not read policies a b o u t service provision. While we cannot conclude causal relationships in either direction, our findings that fewer of those who had read a d e q u a t e policies were concerned a b o u t resources to provide care for HIV-infected people suggests that there would be value in providing i n f o r m a t i o n to midwives a b o u t plans for and the organisation of services locally, highlighting their implications for midwives. Bearing in m i n d the limitations of a single survey questionnaire administered to all types of c o m m u n i t y nursing staff, the findings presented

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nevertheless suggest some ways forward for managers a n d educators to assist midwives to cope with H I V infection, described by m a n y as 'the biggest public health challenge this century'. While midwives themselves feel they have a role to play in p r e v e n t i n g the spread of H I V infection through health education and in caring for those with H I V infection, there are m a n y who require help to gain the knowledge a n d confidence to enable them to do so.

Acknowledgements These studies were funded by the Department of Health and the Scottish Home and Health Department. We would like to thank our colleagues who assisted in this research: Peter Philips, AlisonJ, Tierney, John Bond, Lilian Simpson,Freda Bolam,Jo Setters and Christopher Foy.

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