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AIDS Care: Psychological and Sociomedical Aspects of AIDS/HIV Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/caic20
Mental health and substance abuse staff: HIV/AIDS knowledge and attitudes a
M. G. Dow & M. D. Knox
a
a
Florida Mental Health Institute, University of South Florida , Tampa, FL, 33612-3899, USA Published online: 25 Sep 2007.
To cite this article: M. G. Dow & M. D. Knox (1991) Mental health and substance abuse staff: HIV/AIDS knowledge and attitudes, AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV, 3:1, 75-87, DOI: 10.1080/09540129108253049 To link to this article: http://dx.doi.org/10.1080/09540129108253049
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
AIDS CARE, VOL. 3, NO. 1, 1991
75
Mental health and substance abuse staff= HIWAIDS knowledge and attitudes M. G. Dow & M. D. KNOX Downloaded by [The University of Manchester Library] at 13:30 10 October 2014
Florida Mental Health Institute, University of South Florida, Tampa, FL 336 2-3899 USLA
Abstract Mental health and substance abuse treatment staff completed a set of measures assessing their attitudes, knowledge, and beliefs concerning AIDS. Results indicated that while most staff were aware of basic information about the disease, approximately one-third were not aware of the neuropsychological and psycho-behavioural concomitants of the disorder. Those surveyed were aware of the main transmission routes, but overgeneralized their concm to casual contact. Most staff indicated willingness to work with HIV-infected individuals, although 29% stated they would try to avoid working with them. Interestingly, mental health staff expressed greater hesitancy than substance abuse stafi These and other results are interpreted to suggest that some desensitization of concern may have already occurred among those who have worked with HIV-positive clients. Individuals who had worked with an HIVpositive client had greater knowledge, less discomfort, and were less likely to want to avoid those who are HIV-positive. Questions attempting to identijj sources of discomfort in working with AIDS or HIV-positive clients suggested that fear of contagion may be the primary concern, followed by discomfort of working with the terminally ill, and then discomfort with IV drug users and homosexuals, The implications of these results for continuing education activities and staff readiness are discussed.
Introduction More than one-half of all USA community mental health centers have treated acquired immunodeficiency syndrome (AIDS) patients (National Council of Community Mental Health Centers, 1988). As the prevalence of HIV infection continues to increase, mental health and substance abuse professionals will see a growing number of HIV-positive and AIDS-affected clients. Many HIV-infected individuals will develop psychological and neuropsychological responses which will bring them into the mentali health service delivery system. These responses include symptoms of depression and anxiety (Faulstich, 1987; Kinnier, 1986; Perry & Markowitz, 1986), suicidal ideation or attempts (Faulstich, 1987; Nichols, 1985; Perry & Markowitz, 1986)) and neurological deficits or organic mental syndromes, including direct infection of the central nervous system by the HIV (Hoffman,
Address for correspondence: Michael G. Dow, Ph.D., Associate Professor and Director of Research, Department of Community Mental Health, Florida Mental Health Institute, University of South Florida, Tampa, FL, 33612-3889, USA.
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76 M. G . DOW & M. D. KNOX 1984; Perry & Jacobsen, 1986). Moreover, many current mental health or substance abuse clients may be at somewhat greater risk for HIV-infection than the general population. Substance abuse clients who use IV drugs or engage in prostitution to acquire drugs are clearly at significant risk. But even the severely mentally ill, as a group, may be somewhat disproportionately at risk for HIV infection because of a somewhat greater prevalence of key risk factors including impaired judgement, lack of impulse control, IV drug use, prostitution, homosexual activities, and multiple sexual partners (Carmen & Brady, 1990; Knox, 1989; Sacks et al., 1990). All of these issues suggest that mental health and substance abuse staff will face rapidly increasing numbers of HIV-infected individuals within their clinical caseloads. It is unclear whether mental health and substance abuse staff are sufficiently prepared to meet the challenge of working with increasing numbers of HIV-infected individuals. The emotional impact of working with HIV-positive individuals is pronounced. Despite their training and education, some mental health and substance abuse professionals may share negative and prejudicial attitudes toward persons with AIDS. Some staff will experience anxiety and uncertainty when treating HIV-positive people, due, in part, to stigmatizing beliefs and prejudices. In order to ensure effective therapeutic conditions, mental health and substance abuse providers must resolve personal biases toward infected individuals, clarify incorrect information, and face their own emotional responses to this devastating disease (Allers & Katrin, 1988; Amchin & Polan, 1986; Polan et al., 1985). Given the increasing prevalence of HIV infection and the uncertainty about whether mental health and substance abuse staff are prepared to meet this challenge, it is now important to assess mental health and substance abuse workers’ knowledge and attitudes concerning AIDS-related issues. This provides a first step toward ensuring humane and therapeutic care of HIV-infected patients. Some relevant research has been conducted in this area, although not on a population of mental health or substance abuse workers. It was shown that health care workers often attribute negative characteristics to people with AIDS (Katz et al., 1987) and have an undue fear of them (Blumenfield et al., 1987). Kelly and his colleagues (Kelly et al., 1987a, 1987b) found that both medical students and practicing physicians held harsh and judgmental attitudes toward AIDS patients as compared to leukemia patients. The subjects were much less willing to engage in routine activities or have a conversation with an AIDS patient. Health care workers sampled in the studies already conducted-nurses, medical students, and physicians-have had extensive education, training, and experience in dealing with contagious disease and very ill people. Yet, they appear to express unreasonable beliefs and attitudes about AIDS. Many mental health and substance abuse providers have had considerably less training and experience with infectious diseases but are coming into contact with HIV-infected individuals with increasing frequency. Aversion to working with HIV-positive or AIDS patients may stem from several sources (Douglas et al., 1985; Herek & Glunt, 1988). Some staff may fear the possibility of acquiring the disease through job-related contact. Others may be uncomfortable because they have insufficient training or knowledge in this area. Some may be uncomfortable working with the terminally ill, homosexuals, or IV drug users. No study has yet attempted to clarify the relative importance of these potential sources of discomfort. The identification of knowledge deficits, attitudinal concerns, and reasons for discomfort among staff who work with mental health and substance abuse clients are all crucial if we are to determine staff readiness to undertake the care of persons with AIDS, develop or improve training and continuing education programs, or make other administrative interventions to improve the quality of care. Anticipating these important considerations, and
HIV/AIDS KNOWLEDGE AND ATTITUDES
77
reflecting the lack of relevant information, this study examined the knowledge and attitudes of mental health and substance abuse providers concerning AIDS.
Method
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Subjects Six hundred and forty-three subjects completed the survey. Sixty-three per cent worked primarily with mental health clients and 31 % worked primarily with substance abuse clients. The remaining 6% checked both categories, contrary to instructions. Subjects ranged in age from 20 to 74 years, with a mean of 38 and a median of 37 years. Forty per cent were male and 60% were female. Seventy-seven per cent were white, 12% black, 6% Hispanic, and 5% were other racial groups. Forty-eight per cent were married, 24% separated/divorced/ widowed, 23% single/never married, and 5% cohabiting. The educational distribution was: high school, 3%; some college, 14%; college degree, 27%; graduate studies, 13%; master’s degree, 38%; doctorate, 5%; and M.D., 1%. The most frequent occupations were: counselor, 47%; social worker, 16%; nurse, 9%; administrator, 7%; psychologist, 5%; and techniciadaide, 5%.
Procedure Treatment facilities were randomly selected from all Community Mental Health Centers and all public-funded drug abuse treatment programs in Florida. Twelve programs were identified from each list. One facility that offered services for mental health and drug abuse was selected from both lists, so a total of 23 programs were approached for participation in this survey. Of these programs, 22 participated in the survey. During the latter half of 1988, one of two psychologists working on this project met with the Director or Clinical Director of each program and interviewed them concerning administrative barriers to working with HIV-infected individuals (Dow et al., 1989). The psychologist then explained the staff survey to the Director and other supervisory staff. Copies of the questionnaire were left with supervisory staff in stamped return envelopes to distribute to all clinical/direct care staff. Individual respondents returned the questionnaires by mail. The survey instrument was composed of four parts and took approximately 20-25 minutes to complete. The first part consisted of 38 true-false questions regarding knowledge of AIDS, HIV-transmission, testing, mental health aspects of AIDS, and other related items. The second part involved 33 opinion-oriented questions assessing attitudes toward working with HIV-infected individuals and perceived risk of acquiring the disease in various situations. These questions were adapted from the study by Wertz er al. (1987). The third part assessed discomfort level and reasons for discomfort in working with 1 1 different types of clients including those engaging in high-risk behaviors for AIDS, those who are HIVpositive, and persons with AIDS. The final scale requested demographic and subject characteristic information. A total of 1,481 surveys were left for distribution to staff at 22 facilities. The return rate from one center was judged unacceptably low (18%), so this center was dropped. For the remaining 21 facilities, 643 out of 1,381 questionnaires were completed and returned, for a return rate of 47%.
78 M. G . DOW & M. D. KNOX Results
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Knowledge scale
There was no significant difference on the Knowledge scale between mental health and substance abuse staff, F(1, 592)= 1.51, p t 0 . 2 2 , between male and female subjects, F(1, 592)=2.36, p(0.13, nor for the interaction, F(1, 592)= 1.04, ~ ( 0 . 3 1 . The Knowledge scale score did correspond with educational degree level, F( 1, 632)= 17.12, ptO.0001. Those with a high school degree averaged 80% correct; Bachelor’s degree, 83%; Masters, 86%; and Doctorate/M.D., 88%. Across all staff, the mean Knowledge scale score was 84% correct. While not necessarily designed to be unidimensional, the scale was reasonably internally consistent, Cronbach alpha= 0.57. Some of the items answered incorrectly most often are shown in Table 1 and indicated knowledge deficits as follows: many staff were not aware of the neuropsychological aspects of HIV infection; staff overestimated the proportion of people infected by sexual contact, but underestimated the proportion infected by heterosexual contact; staff overestimated the risk of infection from a needle-stick, staff minimized the risk of infection from receiving blood transfusions or from having sex using condoms; and many staff were not aware that an HIV-infected person may take a considerable time to show symptoms of serious illness or to develop AIDS. Basic items which were answered correct most often included: needle-sharing is a high risk activity (loo%), having many heterosexual partners increases risk of HIV infection (99%), a pregnant woman can pass on the virus to her baby (98%), a person can be infected for several months before testing positive on an antibody test (97%), etc. Table 1. Selected knowledge scale results Item Neuropsychological difficulties may be one of the first problems to develop as a result of HIV infection (T) In the US, at least 95% of the people who have AIDS contracted the infection through sexual contact (F) If a nurse is accidentally stuck by a needle used on an HIV-infected person, she will almost surely become infected with HIV (F) Recent studies in the US have shown that no more than 1% of people infected with HIV acquired their infection through heterosexual contact (F) When donated blood is screened for HIV antibodies, there is still a small chance that a person could be infected with HIV by receiving a blood transfusion (T) Some symptoms of HIV infection may include (but are not limited to): forgetfulness, poor concentration, psychomotor retardation, apathy, and social withdrawal (T) All persons who are infected with HIV will develop AIDS within the first five years after exposure (F) It is impossible to get AIDS from sexual intercourse if you use condoms carefully (F) HIV infection may produce a slowly progressing dementia (T) Most people who have been infected with HIV show symptoms of serious illness within 6 months (F)
% Correct
63% 63% 67% 73% 76%
76% 76% 79% 79% 79%
Opinion scale A cluster analysis was conducted on the sixteen truelfalse items of the Opinion scale, indicating two major clusters of variables and three other items which did not fit readily into
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either cluster. The first cluster consisted of five items concerning HIV testing (Cronbach alpha=0.85). The ANOVA on the sum of these items indicated no differences for staff type (mental health vs. substance abuse), subject gender, or the interaction (p>0.50 for each effect). The per cent of staff who agreed with each item is shown in Table 2. Generally, it appears that more staff believed that HIV-testing should be conducted for inpatients than for outpatients. Also, more staff believed that substance abuse patients should be tested compared with mental health patients. A surprising number (23%) felt that all staff at their facility should be tested for HIV. The correlation of the Knowledge scale score with this cluster of opinion items was r=0.22, p(0.01, indicating that staff with greater knowledge tended to be less likely to advocate testing. Table 2. Opinion scale results Item
HIV Testing All MH inpatients should be tested for HIV All SA inpatients should be tested for HIV All M H outpatients should be tesed for HIV All SA outpatients should be tested for HIV All staff at my facility should be tesed for HIV Approach-avoidance If I had a choice, I would prefer to avoid working with an HIV-infected person I would try to avoid working with patients who are HIV-positive I would be afraid of acquiring AIDS if I worked on a unit with HIV-positive patients General medical professionals and paraprofessionals should not be required to work with HIV-positive patients MH professionals and paraprofessionals should not be required to work with HIV-positive patients SA professionals and paraprofessionals should not be required to work with HIV-positive patients M H and SA inpatients who are HIV-positive should only be treated on specialized units for HIV-positive patients HIV-positive individuals should not be admitted to my program Other Items I would feel comfortable talking with a person who I knew was infected with the AIDS virus Staff should be informed which patients are HIV-positive Inpatients should be informed which inpatients on their unit are HIV-positive
% Agree
46% 63% 24% 43% 23%
55% 29% 40%
(MH 24%, SA 16%) (MH 28%, SA 20%) 24%
(MH 39%, SA 30%) (MH 16%, SA 10%)
( M 73%, F 81%) 83% 40%
The second cluster of Opinion scale items consisted of eight items which dealt with approach-avoidance of HIV-infected persons (Cronbach alpha =0.84). The ANOVA on the sum of these items indicated that mental health staff had a greater desire to avoid HIVpositive clients compared with substance abuse staff, F( 1, 587)=4.81, ~ ( 0 . 0 3 , and males had a greater desire to avoid than females, F( 1,587) =3.98, ~(0.05). The interaction was nonsignificant. Follow-up Chi-square analysis for staff type and subject gender were conducted for each item. Results are shown in Table 2 broken down for either respective categorization if that effect was significant, p (0.05; otherwise the overall percentage is shown. Results indicated that 55% of staff would prefer to avoid working with an HIVinfected person, while only 29% said they would actually try to avoid working with patients
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80 M. G . DOW & M. D. KNOX
who are HIV-positive. Forty per cent of staff indicated they would be afraid of acquiring AIDS if they were to work on a unit with HIV-positive patients. The chi-square test indicated that, compared with substance abuse staff, mental health staff were more likely to believe that both general medical and mental health professionals should not be required to work with HIV-positive individuals. Interestingly, mental health and substance abuse staff did not differ in their perception of whether substance abuse professionals should be required to work with HIV-positive patients. Fewer subjects indicated that general medical professionals and paraprofessionals should not be required to work with HIV-positive patients compared with their views for staff working with substance abuse or mental health patients. Mental health staff were more likely to indicate that HIV-infected mental health and substance abuse inpatients should only be treated on specialized units for HIV-positive patients, compared with substance abuse staff. Mental health staff were also more inclined to believe that HIV-positive individuals should not be admitted to the program they worked on. The correlation of the approach/avoidance cluster with the Knowledge scale was r= 0.20, pKO.01, indicating that staff with greater knowledge tended to show less avoidance of HIVpositive persons.
Perceived risk from touching bodily fluids. Staff rated the likelihood of acquiring HIV infection if they were to touch bodily fluids from an HIV-positive person. These ratings were made using the following scale: (1) very likely, (2) somewhat likely, (3) possible, but unlikely, (4) practically impossible, and (5) impossible. Results of a staff type (mental health vs. substance abuse) X subject gender X type of fluid* ANOVA indicated a significant effect for type of fluid, F(5, 1905.3)=559.12, ptO.0001). None of the other effects or interactions was significant. Subjects believed that transmission by touching either blood (M= 1.84) or semen (M= 1.84) was somewhat likely. Vaginal fluids (M= 1.98) were viewed as significantly less risky but still somewhat likely, followed by urine (M=2.95) and then sputum/saliva (M= 3.16), which were viewed as possible, but unlikely. Touching tears (M=3.74) was viewed as practically impossible to transmit the virus. Bonferroni post hoc comparisons indicated that each of these means was significantly different from all others, except for blood and semen which had the same mean. Perceived riskfrom work activities. Subjects used the same 1-5 scale to rate the likelihood of acquiring HIV infection if they were to be involved in certain work-related situations with an infected client. Because results should not be biased by subjects who did not perform certain tasks, subjects indicated ‘not applicable’ for any situation that they would not be involved in. This code was primarily used for three items: working with a blood sample (16%), cleaning vomitus (14%), and being stuck by a needle (10%). Results suggested that the most concern was for needle-stick, which with a mean of 1.58 was between the scale anchors of ‘very likely’ and ‘somewhat likely’. Working with a blood sample (M=2.14), being bitten by a patient (M=2.22), and touching blood when applying pressure to stop bleeding (M=2.25) were all rated in the ‘somewhat likely’ range. Mouth to mouth CPR (M=2.62) was somewhat less of a concern, having been rated between ‘somewhat likely’ and ‘possible, but unlikely’. Cleaning vomitus ( M = 3 . 3 3 ) and being spit on by a patient (M=3.37) were viewed in the ‘possible, but unlikely’ range. Being sneezed or coughed on (M=3.85) and sitting on a toilet seat (M=4.22) were rated close to ‘practically impossible’.
* The Greenhouse-Geisser procedure was used to estimate the preferred, more conservative degrees of freedom and probability estimates for all repeated measures effects in this study (Winer, 1971).
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Shaking hands (M=4.65) and touching a doorknob (M=4.69) were rated closest to the ‘impossible’ scale anchor.
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Staff &comfm Scale Discomfort ratings. Subjects rated how much discomfort they would have in working with the following types of clients: ( 1 ) has major depressive disorder (MDD), (2) is homosexual (HOM), (3) is an IV drug user (IV), (4) has AIDS (AIDS), (5) has hepatitis B (HPT-B), (6) is a homosexual who is HIV-positive (HOMHIV+), (7) is terminally ill .(TERM), (8) is HIV-positive (HIV+), (9) is a homosexual with fatal genetic disease (HOMFT), (10) is a child molester (CHILDM), ( 1 1) has syphilis or gonorrhea (SYPH). Subjects rated their discomfort on a 0-6 scale ranging from ‘no discomfort’ to ‘much discomfort’. A two-way ANOVA* indicated significant differences between mental health and substance abuse staff, F( 1, 579) =6.23, ~ ( 0 . 0 2 , significant differences across client descriptions rated, F( 7.2, 4192.5)= 151.83, p
AIDS Care: Psychological and Sociomedical Aspects of AIDS/HIV Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/caic20
Mental health and substance abuse staff: HIV/AIDS knowledge and attitudes a
M. G. Dow & M. D. Knox
a
a
Florida Mental Health Institute, University of South Florida , Tampa, FL, 33612-3899, USA Published online: 25 Sep 2007.
To cite this article: M. G. Dow & M. D. Knox (1991) Mental health and substance abuse staff: HIV/AIDS knowledge and attitudes, AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV, 3:1, 75-87, DOI: 10.1080/09540129108253049 To link to this article: http://dx.doi.org/10.1080/09540129108253049
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
AIDS CARE, VOL. 3, NO. 1, 1991
75
Mental health and substance abuse staff= HIWAIDS knowledge and attitudes M. G. Dow & M. D. KNOX Downloaded by [The University of Manchester Library] at 13:30 10 October 2014
Florida Mental Health Institute, University of South Florida, Tampa, FL 336 2-3899 USLA
Abstract Mental health and substance abuse treatment staff completed a set of measures assessing their attitudes, knowledge, and beliefs concerning AIDS. Results indicated that while most staff were aware of basic information about the disease, approximately one-third were not aware of the neuropsychological and psycho-behavioural concomitants of the disorder. Those surveyed were aware of the main transmission routes, but overgeneralized their concm to casual contact. Most staff indicated willingness to work with HIV-infected individuals, although 29% stated they would try to avoid working with them. Interestingly, mental health staff expressed greater hesitancy than substance abuse stafi These and other results are interpreted to suggest that some desensitization of concern may have already occurred among those who have worked with HIV-positive clients. Individuals who had worked with an HIVpositive client had greater knowledge, less discomfort, and were less likely to want to avoid those who are HIV-positive. Questions attempting to identijj sources of discomfort in working with AIDS or HIV-positive clients suggested that fear of contagion may be the primary concern, followed by discomfort of working with the terminally ill, and then discomfort with IV drug users and homosexuals, The implications of these results for continuing education activities and staff readiness are discussed.
Introduction More than one-half of all USA community mental health centers have treated acquired immunodeficiency syndrome (AIDS) patients (National Council of Community Mental Health Centers, 1988). As the prevalence of HIV infection continues to increase, mental health and substance abuse professionals will see a growing number of HIV-positive and AIDS-affected clients. Many HIV-infected individuals will develop psychological and neuropsychological responses which will bring them into the mentali health service delivery system. These responses include symptoms of depression and anxiety (Faulstich, 1987; Kinnier, 1986; Perry & Markowitz, 1986), suicidal ideation or attempts (Faulstich, 1987; Nichols, 1985; Perry & Markowitz, 1986)) and neurological deficits or organic mental syndromes, including direct infection of the central nervous system by the HIV (Hoffman,
Address for correspondence: Michael G. Dow, Ph.D., Associate Professor and Director of Research, Department of Community Mental Health, Florida Mental Health Institute, University of South Florida, Tampa, FL, 33612-3889, USA.
Downloaded by [The University of Manchester Library] at 13:30 10 October 2014
76 M. G . DOW & M. D. KNOX 1984; Perry & Jacobsen, 1986). Moreover, many current mental health or substance abuse clients may be at somewhat greater risk for HIV-infection than the general population. Substance abuse clients who use IV drugs or engage in prostitution to acquire drugs are clearly at significant risk. But even the severely mentally ill, as a group, may be somewhat disproportionately at risk for HIV infection because of a somewhat greater prevalence of key risk factors including impaired judgement, lack of impulse control, IV drug use, prostitution, homosexual activities, and multiple sexual partners (Carmen & Brady, 1990; Knox, 1989; Sacks et al., 1990). All of these issues suggest that mental health and substance abuse staff will face rapidly increasing numbers of HIV-infected individuals within their clinical caseloads. It is unclear whether mental health and substance abuse staff are sufficiently prepared to meet the challenge of working with increasing numbers of HIV-infected individuals. The emotional impact of working with HIV-positive individuals is pronounced. Despite their training and education, some mental health and substance abuse professionals may share negative and prejudicial attitudes toward persons with AIDS. Some staff will experience anxiety and uncertainty when treating HIV-positive people, due, in part, to stigmatizing beliefs and prejudices. In order to ensure effective therapeutic conditions, mental health and substance abuse providers must resolve personal biases toward infected individuals, clarify incorrect information, and face their own emotional responses to this devastating disease (Allers & Katrin, 1988; Amchin & Polan, 1986; Polan et al., 1985). Given the increasing prevalence of HIV infection and the uncertainty about whether mental health and substance abuse staff are prepared to meet this challenge, it is now important to assess mental health and substance abuse workers’ knowledge and attitudes concerning AIDS-related issues. This provides a first step toward ensuring humane and therapeutic care of HIV-infected patients. Some relevant research has been conducted in this area, although not on a population of mental health or substance abuse workers. It was shown that health care workers often attribute negative characteristics to people with AIDS (Katz et al., 1987) and have an undue fear of them (Blumenfield et al., 1987). Kelly and his colleagues (Kelly et al., 1987a, 1987b) found that both medical students and practicing physicians held harsh and judgmental attitudes toward AIDS patients as compared to leukemia patients. The subjects were much less willing to engage in routine activities or have a conversation with an AIDS patient. Health care workers sampled in the studies already conducted-nurses, medical students, and physicians-have had extensive education, training, and experience in dealing with contagious disease and very ill people. Yet, they appear to express unreasonable beliefs and attitudes about AIDS. Many mental health and substance abuse providers have had considerably less training and experience with infectious diseases but are coming into contact with HIV-infected individuals with increasing frequency. Aversion to working with HIV-positive or AIDS patients may stem from several sources (Douglas et al., 1985; Herek & Glunt, 1988). Some staff may fear the possibility of acquiring the disease through job-related contact. Others may be uncomfortable because they have insufficient training or knowledge in this area. Some may be uncomfortable working with the terminally ill, homosexuals, or IV drug users. No study has yet attempted to clarify the relative importance of these potential sources of discomfort. The identification of knowledge deficits, attitudinal concerns, and reasons for discomfort among staff who work with mental health and substance abuse clients are all crucial if we are to determine staff readiness to undertake the care of persons with AIDS, develop or improve training and continuing education programs, or make other administrative interventions to improve the quality of care. Anticipating these important considerations, and
HIV/AIDS KNOWLEDGE AND ATTITUDES
77
reflecting the lack of relevant information, this study examined the knowledge and attitudes of mental health and substance abuse providers concerning AIDS.
Method
Downloaded by [The University of Manchester Library] at 13:30 10 October 2014
Subjects Six hundred and forty-three subjects completed the survey. Sixty-three per cent worked primarily with mental health clients and 31 % worked primarily with substance abuse clients. The remaining 6% checked both categories, contrary to instructions. Subjects ranged in age from 20 to 74 years, with a mean of 38 and a median of 37 years. Forty per cent were male and 60% were female. Seventy-seven per cent were white, 12% black, 6% Hispanic, and 5% were other racial groups. Forty-eight per cent were married, 24% separated/divorced/ widowed, 23% single/never married, and 5% cohabiting. The educational distribution was: high school, 3%; some college, 14%; college degree, 27%; graduate studies, 13%; master’s degree, 38%; doctorate, 5%; and M.D., 1%. The most frequent occupations were: counselor, 47%; social worker, 16%; nurse, 9%; administrator, 7%; psychologist, 5%; and techniciadaide, 5%.
Procedure Treatment facilities were randomly selected from all Community Mental Health Centers and all public-funded drug abuse treatment programs in Florida. Twelve programs were identified from each list. One facility that offered services for mental health and drug abuse was selected from both lists, so a total of 23 programs were approached for participation in this survey. Of these programs, 22 participated in the survey. During the latter half of 1988, one of two psychologists working on this project met with the Director or Clinical Director of each program and interviewed them concerning administrative barriers to working with HIV-infected individuals (Dow et al., 1989). The psychologist then explained the staff survey to the Director and other supervisory staff. Copies of the questionnaire were left with supervisory staff in stamped return envelopes to distribute to all clinical/direct care staff. Individual respondents returned the questionnaires by mail. The survey instrument was composed of four parts and took approximately 20-25 minutes to complete. The first part consisted of 38 true-false questions regarding knowledge of AIDS, HIV-transmission, testing, mental health aspects of AIDS, and other related items. The second part involved 33 opinion-oriented questions assessing attitudes toward working with HIV-infected individuals and perceived risk of acquiring the disease in various situations. These questions were adapted from the study by Wertz er al. (1987). The third part assessed discomfort level and reasons for discomfort in working with 1 1 different types of clients including those engaging in high-risk behaviors for AIDS, those who are HIVpositive, and persons with AIDS. The final scale requested demographic and subject characteristic information. A total of 1,481 surveys were left for distribution to staff at 22 facilities. The return rate from one center was judged unacceptably low (18%), so this center was dropped. For the remaining 21 facilities, 643 out of 1,381 questionnaires were completed and returned, for a return rate of 47%.
78 M. G . DOW & M. D. KNOX Results
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Knowledge scale
There was no significant difference on the Knowledge scale between mental health and substance abuse staff, F(1, 592)= 1.51, p t 0 . 2 2 , between male and female subjects, F(1, 592)=2.36, p(0.13, nor for the interaction, F(1, 592)= 1.04, ~ ( 0 . 3 1 . The Knowledge scale score did correspond with educational degree level, F( 1, 632)= 17.12, ptO.0001. Those with a high school degree averaged 80% correct; Bachelor’s degree, 83%; Masters, 86%; and Doctorate/M.D., 88%. Across all staff, the mean Knowledge scale score was 84% correct. While not necessarily designed to be unidimensional, the scale was reasonably internally consistent, Cronbach alpha= 0.57. Some of the items answered incorrectly most often are shown in Table 1 and indicated knowledge deficits as follows: many staff were not aware of the neuropsychological aspects of HIV infection; staff overestimated the proportion of people infected by sexual contact, but underestimated the proportion infected by heterosexual contact; staff overestimated the risk of infection from a needle-stick, staff minimized the risk of infection from receiving blood transfusions or from having sex using condoms; and many staff were not aware that an HIV-infected person may take a considerable time to show symptoms of serious illness or to develop AIDS. Basic items which were answered correct most often included: needle-sharing is a high risk activity (loo%), having many heterosexual partners increases risk of HIV infection (99%), a pregnant woman can pass on the virus to her baby (98%), a person can be infected for several months before testing positive on an antibody test (97%), etc. Table 1. Selected knowledge scale results Item Neuropsychological difficulties may be one of the first problems to develop as a result of HIV infection (T) In the US, at least 95% of the people who have AIDS contracted the infection through sexual contact (F) If a nurse is accidentally stuck by a needle used on an HIV-infected person, she will almost surely become infected with HIV (F) Recent studies in the US have shown that no more than 1% of people infected with HIV acquired their infection through heterosexual contact (F) When donated blood is screened for HIV antibodies, there is still a small chance that a person could be infected with HIV by receiving a blood transfusion (T) Some symptoms of HIV infection may include (but are not limited to): forgetfulness, poor concentration, psychomotor retardation, apathy, and social withdrawal (T) All persons who are infected with HIV will develop AIDS within the first five years after exposure (F) It is impossible to get AIDS from sexual intercourse if you use condoms carefully (F) HIV infection may produce a slowly progressing dementia (T) Most people who have been infected with HIV show symptoms of serious illness within 6 months (F)
% Correct
63% 63% 67% 73% 76%
76% 76% 79% 79% 79%
Opinion scale A cluster analysis was conducted on the sixteen truelfalse items of the Opinion scale, indicating two major clusters of variables and three other items which did not fit readily into
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either cluster. The first cluster consisted of five items concerning HIV testing (Cronbach alpha=0.85). The ANOVA on the sum of these items indicated no differences for staff type (mental health vs. substance abuse), subject gender, or the interaction (p>0.50 for each effect). The per cent of staff who agreed with each item is shown in Table 2. Generally, it appears that more staff believed that HIV-testing should be conducted for inpatients than for outpatients. Also, more staff believed that substance abuse patients should be tested compared with mental health patients. A surprising number (23%) felt that all staff at their facility should be tested for HIV. The correlation of the Knowledge scale score with this cluster of opinion items was r=0.22, p(0.01, indicating that staff with greater knowledge tended to be less likely to advocate testing. Table 2. Opinion scale results Item
HIV Testing All MH inpatients should be tested for HIV All SA inpatients should be tested for HIV All M H outpatients should be tesed for HIV All SA outpatients should be tested for HIV All staff at my facility should be tesed for HIV Approach-avoidance If I had a choice, I would prefer to avoid working with an HIV-infected person I would try to avoid working with patients who are HIV-positive I would be afraid of acquiring AIDS if I worked on a unit with HIV-positive patients General medical professionals and paraprofessionals should not be required to work with HIV-positive patients MH professionals and paraprofessionals should not be required to work with HIV-positive patients SA professionals and paraprofessionals should not be required to work with HIV-positive patients M H and SA inpatients who are HIV-positive should only be treated on specialized units for HIV-positive patients HIV-positive individuals should not be admitted to my program Other Items I would feel comfortable talking with a person who I knew was infected with the AIDS virus Staff should be informed which patients are HIV-positive Inpatients should be informed which inpatients on their unit are HIV-positive
% Agree
46% 63% 24% 43% 23%
55% 29% 40%
(MH 24%, SA 16%) (MH 28%, SA 20%) 24%
(MH 39%, SA 30%) (MH 16%, SA 10%)
( M 73%, F 81%) 83% 40%
The second cluster of Opinion scale items consisted of eight items which dealt with approach-avoidance of HIV-infected persons (Cronbach alpha =0.84). The ANOVA on the sum of these items indicated that mental health staff had a greater desire to avoid HIVpositive clients compared with substance abuse staff, F( 1, 587)=4.81, ~ ( 0 . 0 3 , and males had a greater desire to avoid than females, F( 1,587) =3.98, ~(0.05). The interaction was nonsignificant. Follow-up Chi-square analysis for staff type and subject gender were conducted for each item. Results are shown in Table 2 broken down for either respective categorization if that effect was significant, p (0.05; otherwise the overall percentage is shown. Results indicated that 55% of staff would prefer to avoid working with an HIVinfected person, while only 29% said they would actually try to avoid working with patients
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80 M. G . DOW & M. D. KNOX
who are HIV-positive. Forty per cent of staff indicated they would be afraid of acquiring AIDS if they were to work on a unit with HIV-positive patients. The chi-square test indicated that, compared with substance abuse staff, mental health staff were more likely to believe that both general medical and mental health professionals should not be required to work with HIV-positive individuals. Interestingly, mental health and substance abuse staff did not differ in their perception of whether substance abuse professionals should be required to work with HIV-positive patients. Fewer subjects indicated that general medical professionals and paraprofessionals should not be required to work with HIV-positive patients compared with their views for staff working with substance abuse or mental health patients. Mental health staff were more likely to indicate that HIV-infected mental health and substance abuse inpatients should only be treated on specialized units for HIV-positive patients, compared with substance abuse staff. Mental health staff were also more inclined to believe that HIV-positive individuals should not be admitted to the program they worked on. The correlation of the approach/avoidance cluster with the Knowledge scale was r= 0.20, pKO.01, indicating that staff with greater knowledge tended to show less avoidance of HIVpositive persons.
Perceived risk from touching bodily fluids. Staff rated the likelihood of acquiring HIV infection if they were to touch bodily fluids from an HIV-positive person. These ratings were made using the following scale: (1) very likely, (2) somewhat likely, (3) possible, but unlikely, (4) practically impossible, and (5) impossible. Results of a staff type (mental health vs. substance abuse) X subject gender X type of fluid* ANOVA indicated a significant effect for type of fluid, F(5, 1905.3)=559.12, ptO.0001). None of the other effects or interactions was significant. Subjects believed that transmission by touching either blood (M= 1.84) or semen (M= 1.84) was somewhat likely. Vaginal fluids (M= 1.98) were viewed as significantly less risky but still somewhat likely, followed by urine (M=2.95) and then sputum/saliva (M= 3.16), which were viewed as possible, but unlikely. Touching tears (M=3.74) was viewed as practically impossible to transmit the virus. Bonferroni post hoc comparisons indicated that each of these means was significantly different from all others, except for blood and semen which had the same mean. Perceived riskfrom work activities. Subjects used the same 1-5 scale to rate the likelihood of acquiring HIV infection if they were to be involved in certain work-related situations with an infected client. Because results should not be biased by subjects who did not perform certain tasks, subjects indicated ‘not applicable’ for any situation that they would not be involved in. This code was primarily used for three items: working with a blood sample (16%), cleaning vomitus (14%), and being stuck by a needle (10%). Results suggested that the most concern was for needle-stick, which with a mean of 1.58 was between the scale anchors of ‘very likely’ and ‘somewhat likely’. Working with a blood sample (M=2.14), being bitten by a patient (M=2.22), and touching blood when applying pressure to stop bleeding (M=2.25) were all rated in the ‘somewhat likely’ range. Mouth to mouth CPR (M=2.62) was somewhat less of a concern, having been rated between ‘somewhat likely’ and ‘possible, but unlikely’. Cleaning vomitus ( M = 3 . 3 3 ) and being spit on by a patient (M=3.37) were viewed in the ‘possible, but unlikely’ range. Being sneezed or coughed on (M=3.85) and sitting on a toilet seat (M=4.22) were rated close to ‘practically impossible’.
* The Greenhouse-Geisser procedure was used to estimate the preferred, more conservative degrees of freedom and probability estimates for all repeated measures effects in this study (Winer, 1971).
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Shaking hands (M=4.65) and touching a doorknob (M=4.69) were rated closest to the ‘impossible’ scale anchor.
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Staff &comfm Scale Discomfort ratings. Subjects rated how much discomfort they would have in working with the following types of clients: ( 1 ) has major depressive disorder (MDD), (2) is homosexual (HOM), (3) is an IV drug user (IV), (4) has AIDS (AIDS), (5) has hepatitis B (HPT-B), (6) is a homosexual who is HIV-positive (HOMHIV+), (7) is terminally ill .(TERM), (8) is HIV-positive (HIV+), (9) is a homosexual with fatal genetic disease (HOMFT), (10) is a child molester (CHILDM), ( 1 1) has syphilis or gonorrhea (SYPH). Subjects rated their discomfort on a 0-6 scale ranging from ‘no discomfort’ to ‘much discomfort’. A two-way ANOVA* indicated significant differences between mental health and substance abuse staff, F( 1, 579) =6.23, ~ ( 0 . 0 2 , significant differences across client descriptions rated, F( 7.2, 4192.5)= 151.83, p
