Sociodemographic Determinants of Knowledge, Attitude and Practices of Ghanaian Nurses

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Towards Persons Living with HIV and AIDS in Kumasi.
AUTHOR AFFILIATION
Dorothy Serwaa Boakye1, Emmanuel Konadu2, Azwihangwisi Helena Mavhandu-Mudzusi3

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1Department of Health Administration and Education, University of Education, Winneba, Ghana
2 University Health Services, Kwame Nkrumah University of Science and Technology, Kumasi,
Ghana
3Department of Health Studies, University of South Africa, Pretoria, South Africa

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Corresponding author: Dorothy Serwaa Boakye

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Institutional Address: Department of Health Administration and Education, University of
Education, Winneba, Ghana
Postal Address: P.O.Box 11041, Adum, Kumasi
Email address: [email protected] (Boakye D. S)
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This preprint research paper has not been peer reviewed. Electronic copy available at: https://ssrn.com/abstract=4068203
 Sociodemographic Determinants of Knowledge, Attitude and Practices of Ghanaian Nurses
Towards Persons Living with HIV and AIDS in Kumasi.

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Abstract: Introduction: Despite increasing knowledge, and awareness on HIV/AIDS, Countries and health
institutions are still struggling to deal with the issues of stigma and discrimination towards patients living
with HIV and AIDS amongst its staff. An investigation into other potential determinants/influences of
nurses’ knowledge, attitudes, and practices towards HIV/AIDS such as sociodemographic factors is

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therefore necessary. Methods: A total of 247 participants from five chosen health facilities were recruited
for the study. The data was collected using a self-administered questionnaire and was analyzed using SPSS
version 23. Chi-square analysis and Spearman's rank correlation were used to measure the level of
association between the dependent and the independent variables. Results: The study reported a significant
correlation between nurses' knowledge and professional rank, year of work experience, training in HIV

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management, age, and their practice [(r=0.216; p=0.002), (r=0.278; p=0.0001), (r=0.174; p=0.010),
(r=0.173; r=0.011), and (r=0.176; p=0.011)] respectively. Also, a significant correlation was observed
between practice and age of the nurses (r = 0.151, p=0.030). The attitude was positively associated with
knowledge, professional rank, educational level, work experience, and age but negatively associated with

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practice and training however there was no statistically significant correlation. Conclusion and
Recommendation: Nurses' knowledge was directly associated with HIV/AIDS training which suggests that
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continuous in-service training could be tremendous in impacting the nurses' attitude and practice.

Keywords: Attitude, Ghanaian Nurses, HIV, Knowledge, Practice, Sociodemographic Factors

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1. Introduction
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 Since the beginning of the HIV epidemic, an estimated 78 million people have been infected with HIV,
with nearly half of those people have died due AIDS-related complications [1].

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In Ghana, the prevalence rate of HIV is estimated to be 1.47% amongst ages 15-49 years [2].
Approximately, 250 000 of the population living with HIV and 10 000 deaths per annum makes it a public
health problem in Ghana [3, 4].

Studies on human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS)

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knowledge, attitudes and practices (KAP) among health care workers in developing countries have often
revealed the lack of knowledge about HIV transmission and risk prevention, coupled with the existence of
anxiety for contagion [5, 6]. Nurses being the largest health professional group caring for patients living
with HIV, have always been at the forefront of the HIV epidemic [6]. Investigations into nurses’ attitudes
towards patients with HIV have revealed negative and discriminatory behavior [7]. However, other studies

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have revealed that few nurses show empathic attitudes towards patients living with HIV and AIDS [8, 9].

Nurses’ knowledge may compromise the quality of care and attitudes towards patients living with HIV and
AIDS. Special nursing knowledge and skills have been suggested as requisite for taking care of patients

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living with HIV by nurses [9, 10, 11]. The general negative feelings and views about the care of HIV
infected patients among some nurses could be attributed to misconceptions about HIV [12]. Gitachu has
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attributed HIV/AIDS stigma and discrimination in the health care setting to a lack of knowledge about HIV
and AIDS and fear of contracting HIV among professional nurses [10].
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Despite the increasing knowledge in the mode of transmission and guidelines to ensure adequate protection,
most nurses still react with fear, over-protectiveness and over-stringent infection control due to fear of
possible contagion [12]. Studies exploring HIV/AIDS knowledge and attitude of nurses found a varying
degree of HIV/AIDS knowledge among nurses [8, 9].
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With institutions still struggling to deal with the issues of stigma and discrimination towards patients living
with HIV amongst its staff despite increasing knowledge and awareness on HIV/AIDS, an investigation
into potential determinants such as sociodemographic factors of nurses’ knowledge, attitude and practices
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towards HIV/AIDS is necessary.

A study by [13] suggested that stigmatizing attitudes, such as prejudice, discrimination at work, and fear of
AIDS are less likely among nurses with longer years of experience in treating PLWHA. On the contrary, a
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study by [14] revealed that health workers with more than 11 years of service showed greater discriminatory
attitudes, poor tolerance towards HIV/AIDS and more fear. Again, while Ishimaru et al showed middle-
aged nurses between 40 and 49years expressed an increased willingness to care for HIV-infected patients
[7, 15] found that younger nurses tend to have less discriminatory attitudes.
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2. Materials and Methods

2.1. Study Design and Setting

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The researchers employed a quantitative approach while using a descriptive cross-sectional study. These
methods were preferred because it allowed the researchers to gather, describe and explain data regarding
nurses’ knowledge, attitude and practices through the collection of data that are analyzed using

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 mathematically-based statistical methods at a specific point in time without attempting to manipulate or
control the participants.

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This study was conducted in two private health facilities (Clinic [Facility A] and Medical Centre [facility
B]), two public health facilities (University Hospital [facility C] and District Hospital [facility D]), and a
Teaching Hospital (KATH [facility E]) in the Kumasi metropolis. These five facilities were chosen because
they all have HIV clinics that provide HIV counselling, testing services, use the current national guidelines

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issued by the National AIDS/STI Control Programme for their HIV patient treatment and have the longest
history of HIV/AIDS management services in the metropolis.

The teaching hospital has several clinics and directorates, each led by a clinical director, a general manager
and a clinical lead, and are supported by heads of service and matrons that lead each of the several service
areas within the directorates. Each directorate is subdivided into smaller units or departments, each

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encompassing a range of specialist services. The HIV clinic is managed under the medical directorate. The
four other study sites (University Hospital, District Hospital, and the two private health facilities) have one
corporate directorate, led by one director or superintendent. These facilities have further subdivisions, such

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as an out-patient department, a medical/surgical department, obstetrics and gynecology department, public
health units, and pediatric units. All five facilities have registered nurses, doctors, pharmacist, adherence
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counselors, National AIDS Control Programme (NACP)’s models who have tested positive for HIV, and
data managers working in the HIV clinics. Staff capacity, however, differs in each hospital. They all run
HIV clinics, but on separate days, from 8am to 3pm and do not admit or detain patients. However, the
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teaching hospital runs its clinic from Mondays to Fridays.

2.2. Study Population and Sample Size Estimation

The study recruited all registered nurses who were employed to work in the HIV units, wards and
departments in all the five (5) selected health facilities in Kumasi and satisfied the inclusion criteria. The
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inclusion criteria included: participants who are qualified nurses and registered with the Nurses’ and
Midwifery Council (NMC), Ghana, participants who have worked for not less than 3 months in their
respective units/wards, and participants who were between the ages 18 and 65 years. The participants
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selected for the study were proportional to the total number of registered nurses working in the HIV
wards/units of the five selected health facilities. The study determined its estimated sample size using a
formula developed by Yamane in 1967.
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𝑁
𝑛=
1 + 𝑁(𝑒2)
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Using a confidence level of 95%, level of precision of 5%, and a population size (N) of 304, the estimated
sample size (n) was purged at 247.The table below represents the various facilities, the population and the
desired sample size obtained with the Yamane formula.
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 Table 1. Facilities, the population of nurses and desired sample size based on Yamane formula.

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NAME OF TOTAL POPULATION OF
STUDY SAMPLE/SAMPLE SIZE (n)
FACILITY NURSES (N)
Facility A 15 14.47 = 14

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Facility B 36 33
Facility C 55 48
Facility D 52 46
Facility E 146 106

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TOTAL 304 247

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2.3. Sampling

Apart from facility E, the teaching hospital had six (6) medical wards (large rooms with beds in hospitals
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where patients are temporary kept and nursed). The rest of the facilities have two (2), a male medical and
female medical ward. A simple random sampling technique was used to draw equal samples from each
ward to form the representative sample. For example, the required sample size for Facility A was 14.
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Therefore, seven (7) participants were selected from each ward. The attendance register for each day was
used as the sampling frame; a manual lottery technique was used to select the representative sample at
random. The procedure was used to selected two-thirds of the population on the duty roster. Participants
were excluded from the study if they failed to report to work on that day. This method was continued for
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succeeding visits for several days until the expected sample size was obtained. The number of visits to each
facility was determined by the sample size needed. To avoid the repeated selection of the same participants,
any nurse who has had the opportunity to participate in the study was not recorded and allotted a number
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in the lottery on subsequent visits.

2.4. Data Collection

The research instrument employed in this study was a self-administered HIV/AIDS KAP questionnaire
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consisting of 48-items. The instrument as adapted from [16], an open-access study. The questionnaire was
developed in English – a language understood and spoken by all the respondents and it is also the accepted
language for educational instructions in Ghana [17]. The questionnaire included several aspects under
study, including the demographic characteristics, training received on aspects of HIV, knowledge, attitudes,
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and practices related to the care of patients with HIV and AIDS.

The questionnaire was divided into four major sections. The first section was comprised of demographic
characteristics and variables relating to HIV/AIDS training and care, the second section was a 28-item
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HIV/AIDS knowledge scale with statements about disease's clinical presentation, mode of transmission,
precaution, and prevention. The third section was a 10-item attitude scale and comprised of items examining
empathic and preventive behavior. The final section was a 10-item practices scale. This was comprised of

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 questions relating to adherence to universal precaution measures, the demand for and availability of post-
exposure prophylaxis (PEP), and behavior about HIV testing and referral.

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The reliability of the research instrument was measured using Cronbach’s alpha coefficient. A coefficient
for the knowledge and attitude were 0.78 and 0.66 respectively, confirming the reliability and acceptability
of the instrument. The reliability coefficient obtained for the instrument in this study was comparable to
that obtained in the [16] study (0.77 and 0.63). However, slight changes were to the questions. Furthermore,

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the researcher ensured that care was taken over the well-defined phrasing of each question to avoid
vagueness. The instrument was piloted on 15 nurses from the medical wards of the Kumasi South
Government before undertaking the study.

The questionnaires were delivered to the participants and all answered questionnaires were then collected
by the first author. Privacy was ensured while participants were completing the questionnaires. Participants

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who did not have the time to finish the questionnaires were permitted to keep them; these were collected at
the participants’ given time by the first author. To avoid fatigue among the participants, the allocated time
to complete the questionnaires ranged from 15 to 20 minutes. Data were collected for a period of 2 months

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(April to June 2018).

2.5. Ethical Consideration

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Ethical clearance to conduct the study was sought from the Higher Degrees Committee Department of
Health Studies, University of South Africa Research and Ethics, and Committee of Human Publication and
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Research Ethics (CHPRE)-KNUST. Also, permission was obtained from the management and authorities
of the five selected healthcare facilities used in the study. Prior to the administration of the research
instruments, an informed consent was sought from the respondents. The ethical principles of Declaration
of Helsinki were fully observed [18]. Participants’ completion of the questionnaire constituted informed
consent as per the University of South Africa Ethics committee. The researcher also left her contact number
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with each participant to reach her where the need might arise.

2.6 Data analysis

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The data collected was analyzed using Graph Pad Prism 6 and IBM SPSS version 23. Descriptive statistics
(frequency, percentage, mean and standard deviation) were used to present the findings. Also, a chi-square
analysis was used to measure the level of association between the variables and analysis of variance
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(ANOVA) was used to compare the means of the subgroups. A Spearman’s correlation rank co-efficient
was calculated among the dependent variables (KAP scores) and the independent variable
(sociodemographic characteristics). The Spearman’s co-efficient tests the strength of correlation between
the two variables. The coefficient (R) ranges from -1 to +1, with +1 being a perfect positive correlation and
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-1 being a perfect negative correlation [19]. The results were presented in tables.
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3. Results

3.1. Sociodemographic Characteristics of Study Participants

The majority (68.5%) of the participants were females. The minimum and maximum age of the respondents

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were 20 and 60 years respectively. Also, 41.4% of the participants were between the ages of 20 -29 years.
Staff nurses formed a majority (43.19%) of the participants and most of (58.14%) of the participants had
either a diploma or certificate qualification. Work experienced ranged from 2 to 15 years with 2-5 years
being the common range. The majority (71.15%) of the participants worked in public hospitals. A majority
(31.2%) reported caring for HIV and AIDS patients very often.

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3.2. Participants Score on Knowledge, Attitude, and Practices

Table 3 above shows the knowledge, attitude and practice of participants: A majority of the participants

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recorded high score for knowledge (51.9%), attitude (54.7%) and practices (56%).

3.3. Spearman’s Rank Correlation of Knowledge, Attitude and Practice with Selected Demographic
Characteristics of Study Participant
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Table 4 above shows the Spearman correlation of knowledge, attitude and practice with selected
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demographic characteristics of study participants. There was significant direct correlation between
knowledge and professional rank (r=0.216; p=0.002), year of work experience (r=0.278; p=0.0001),
training of HIV management (r=0.174; p=0.010), age (r=0.173; r=0.011), and practice (r=0.176; p=0.011).
There was a significant positive correlation between practice and age (r=0.151; p=0.030).

The attitude was positively associated with knowledge, professional rank, educational level, work
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experience, and age, but negatively associated with practice and training, although the association was not
statistically significant. Again, there was no significant association between knowledge and educational
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level; and between practice and attitude, professional rank, educational level, work experience, and training
(p-value > 0.05)
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 3.4. Association of Mean Scores of Knowledge, Attitude, Practice and Socio-demographic

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Characteristics of Participants
Table 5 above shows the mean scores of knowledge, attitude and practices and their association
with socio-demographic characteristics.

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The professional rank of participants was significantly associated (0.0089, 2.942) with their
knowledge of HIV/AIDS-related issues. Specifically, the significant difference was between those
ranked as SN (1.26 ± 0.24) and PNO (1.40 ± 0.11). Also, work experience was significantly
associated with knowledge of HIV/AIDS (0.0083, 3.521). Participants with 11-15 years’ work
experience scored high for knowledge and practice. The mean knowledge of participants increased
as participants increased in age from 20-29 years (1.23 ± 0.26) to about 50-59 years (1.41 ± 0.09).

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However, participants who are more than 60 years (1.35 ± 0.08) did not have a corresponding
increase in their knowledge. Those in the public hospitals had mean knowledge values of (1.33 ±
0.21) and those in private hospitals had a mean of (1.29 ± 0.23).

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The mean attitude scores of the participants between the ages of 20-29 years (2.22 ± 0.58) and 30-
39 years (2.15 ± 0.45) were higher than those who were less than 20 years (2.05 ± 0.17), but was

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lesser than those who were between the ages of 40-49 years (2.40 ± 0.42), 50-59 years (2.30 ±
0.48) and 60 years (2.43 ± 0.58). The mean attitude values of the participants increased from those
who hold a certificate (2.17 ± 0.47), diploma (2.19 ± 0.57), bachelor’s degree (2.21 ± 0.44) and
master’s (2.24 ± 0.48).
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Gender was significantly associated with HIV/AIDS-related practices (0.0325, 2.154). Females
(1.82 ± 0.19) scored high for HIV/AIDS-related practices than males (1.75 ± 0.27). As
participants’ age from 20-29 years (1.75 ± 0.26) to 40-49 years (1.83 ± 0.21), their mean for
HIV/AIDS-related practices increased. Participants who are more than 60 years of age recorded
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the highest average (1.90 ± 0.17) of HIV/AIDS-related practices.

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4. Discussion
Just as a nursing profession is said to be dominated by females, this is consistent with this study
which reported that majority (68.5%) of the participants were females. The participants’ age
ranged from 20 to 60years, with the most represented age group being 20-29years. A majority of
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the nurses were staff nurses, and most of them were trained at a level below the first degree. Their
work experience ranged from 2 to 15 years; 2-5 years is the range with the highest frequency.
This study investigated the impact of socio-demographic characteristics of nurses’ knowledge,
attitudes and practices towards HIV/AIDS patients. A Spearman Rho correlation test was used to
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determine the relation between the dependent variables (i.e., knowledge, attitude and practice) and
the independent variables (age, educational level, professional qualification etc).
The study reported a significant weak correlation (rho = 0.173, p-value = 0.011) between
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knowledge of the respondents and their age. This finding was in agreement with other studies
which also showed a significant correlation between age and knowledge of nurses towards the care

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 of HIV/AIDS patients [6, 12]. The mean knowledge of participants increased as participants

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increased in age from 20-29 years (1.23 ± 0.26) to about 50-59 years (1.41 ± 0.09). However,
participants who are more than 60 years (1.35 ± 0.08) did not have a corresponding increase in
their knowledge. It is usually believed that increasing age corresponds to a greater degree of
knowledge which was not in the case of this study as the knowledge level declined in participants

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more than 60 years. According to [20], there is an increase in knowledge from 18 years to 50 years
but later on in adulthood, there is either a decline or stability in knowledge acquisition. Several
hypotheses have been suggested to explain this occurrence of which some include generational
confounds in educations, an asymptote on exposure to new information and increased
specialization of one’s knowledge.

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There was also a weak significant correlation between professional ranks and the level of
knowledge. Specifically, the significant difference was between those ranked as SN (1.26 ± 0.24)
and PNO (1.40 ± 0.11). This finding has similar pattern to [12]. This variance could be linked to
the fact that knowledge and attitudes are gained through years of experience and caring for people.

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The findings also reported a significant positive correlation between knowledge and practice.
Thus, an increased in knowledge of HIV/AIDS means an increased in compliance with universal
precautions and HIV prevention practice. This finding was consistent with studies by [21].
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However, it was inconsistent with [22] study conducted in Egypt. In their study, they reported high
knowledge among the respondents, however there was unsatisfying levels of practice among
nurses. This variation in results could be attributed to the study settings – Islam being the
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predominant religion in Egypt. According to [21], most Muslims believe that Islamic faith shields
them from contracting the virus. These beliefs directly or indirectly impact health care practices.
Attitude and HIV related knowledge were positively correlated. In the study, knowledge of HIV
was statistically related to professional rank. SNO and PNO were statistically correlated to
knowledge.
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The results showed that level of education was positively correlated with HIV related knowledge
and attitude with nurses who have attained a master’s degree. The chi-square analysis saw nurses
with master’s degree scoring high for knowledge (1.43 ± 0.11) and attitude (2.24 ± 0.48). However,
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their level of knowledge did not reflect on their practice (1.80 ± 0.14). Nurses with ‘Diploma’
rather scored high on practice (1.83 ± 0.20). To be able to adequately care for patients living with
HIV/AIDS, it requires special knowledge and skills through in-training programs. This study
reported a significant association between HIV training and knowledge. [12] and [2] also observed
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similar trends. An interventional study done in Delhi, reported a significant increase in the
knowledge of nurses after a 48 hours training program [24]. In line with this, researchers have
suggested continuous in-service training for health workers in charge of HIV and AIDS care [14,
25, 26]. This is inconsistent with [6] who showed no correlation between knowledge and
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attendance to HIV/AIDS seminars/lectures. [26] showed a negative correlation instead.

In our study, both the spearman’s rank correlation coefficient and the chi-square analysis showed
no significant correlation between age and attitude. However, [15, 14] and [7] found a significant
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association between these two variables.

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 Work experience was positively correlated with knowledge, attitude and practice, with 11-15 years

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of work experience scoring high for knowledge (1.43 ± 0.12), attitude (2.33 ±0.52), and practice
(1.84 ± 0.18). [16] on the other hand, reported no significant correlation between nurses' work
experience and their knowledge except for nurses' attitude and work experience. Similarly, [13,
14] found a significant correlation between work experience and attitudes while [25] found no

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correlation with regards to work experience and attitude. Generally, nurses with work experience
over 15 years performed better with attitude (2.34 ± 0.47). However, attitude was negatively
correlated with practice, though not statistically significant. Thus, a more favorable attitude was
associated with decreased compliance with universal precautions and HIV preventive practices.
Evidence from international reports seem to collaborate the fact that nurses who undergo

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HIV/AIDS-specific training tends to be more aware of universal precautions for preventing the
risks of occupational HIV transmission [16, 28]. However, our study found no association between
attending HIV training workshops and level of practice. The study also reported a significant
correlation between gender and practices with female nurses scoring higher for practice (1.82 ±

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0.19) than males (1.75 ± 0.27). This was congruent with [28] which reported female health-workers
are more likely to comply with the universal precautionary measures than their male counterparts.
5. Conclusion
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Knowledge was significantly correlated with training on HIV/AIDS, professional rank, work
experience and age. Attitude was positively associated with professional rank, educational level,
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work experience, and age, but negatively associated with training, although the association was
not statistically significant. However, practice did not correlate with professional rank, educational
level, work experience, and training.
Nonetheless, the study showed a correlation between knowledge, attitude and practice. This means
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these variables are interrelated. Therefore, improving knowledge through continuous in-service
training will lead to tremendous noticeable impact on attitude and practice.
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2. UNAIDS. (2018) The global HIV/AIDS Epidemic, viewed 15 June 2018,

fromhttp://www.hiv.gov/hiv-basics/overview/data-and-trends/global-statistics
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fromhttp://www.unaids.org/sites/default/files/media_asset/2014unaidsguidancenote_stig
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This preprint research paper has not been peer reviewed. Electronic copy available at: https://ssrn.com/abstract=4068203