Acquired Immune Deficiency Syndrome (AIDS) is a life-threatening condition which impacts every facet of health care and shows no evidence of declining in incidence. The Centers for Disease Control and Prevention reports that 73,577 HIV-positive (human immunodeficiency virus) cases and 476,899 AIDS cases existed in the United States through June 1995 (CDC and Prevention, 1995). In addition, AIDS incidence among heterosexual, minority, and female populations is increasing at disproportionate rates (Holman & Kelly, 1993). Along with the extensive distribution of ATDS, there are many negative stereotypes and misconceptions about the person living with AIDS (PLWA) which can eventually lead to the etigmatizatiori of the patient and those with whom the patient maintains a relationship (Herek & Glunt, 1988; Brown & Powell-Cope, 1991). Goffinan (1963) views stigma as an interactional process between the person and another who possesses a "differentness" from the expected. When interacting with the discredited, tension develops in the unaSlicted because of dissonance between the virtual social identity (way the other is expected to be) and the actual social identity (way the other actually is). This discomfort can lead to stigmatization of the discredited. Once stigmatized, Goffman believes, the discredited person is not given the same respect or treatment that is accorded to others.
Although many studies address stigma (Brown, Calder & Rae, 1990; Kelly, Lawrence, Smith, Hood, & Cook, 1987; Laryea Sc Gien, 1993; Lawrence & Lawrence, 1989; Lester & Beard, 1988), no studies were found which were guided by a theoretical stigma model. The literature supports that stigmatisation may negatively influence patient care (Jemmott, Preleicher, & Jemmott, 1992; Jemmott, Jemmott, & CruzCollins, 1992). Intentions to provide care are associated with attitudes which may transfer into actual patient care behaviors. Rae, Brown, & Calder (1992) found nurses who have positive attitudes toward PLWAs were more willing to learn about ATDS, therefore increasing their knowledge about this disease. The educational program of nurses represents a formative period in the development of future practice beliefs.
The purpose of this study was to use a stigma theory framework to explore the influence of mode of HTV transmission on attitudes toward PLWAs. Research questions posed were:
1. Do nursing students' attitudes toward the PLWA vary by mode of HTV transmission?
2. Do nursing students' views of the PLWA's deservedness of care vary depending on mode of transmission?
3. Do nursing students' respect and regard for the PLWA vary depending on mode of transmission?
A three-part questionnaire comprised the data collection instrument for this descriptive-correlational study. Following approval by the Institutional Review Board and the College of Nursing's Research Request Review Committee, coded questionnaires were placed in student mailboxes. Follow-up questionnaires were distributed two weeks after the initial distribution to non-respondents and at three weeks non-respondents were contacted by phone.
Study packets were distributed to a convenience sample of 281 baccalaureate program nursing students enrolled in a comprehensive midwestern university. Seventy-five percent of the projected sample (n=212) completed and returned questionnaires. Two questionnaires were determined to be unusable and were deleted, thus leaving a remaining sample of 210. A power analysis done with alpha=. 05, N= 200, effect size=.20 yielded a power of .72.
About three-quarters of each class returned completed questionnaires: 74% juniors, 75% seniors, and 76% career ladder students (RN and LPN students completing a baccalaureate nursing degree). In general, the respondents were female >), Caucasian (86%), and Protestant 0. Over 50% of the respondents had at least two years of patient care experience.
Stigmatizing attitudes toward PLWAs were assessed through the AIDS Attitude Scale (AAS), which was adapted from the measure developed by Kelly and colleagues (1987). Where Kelly's scale compared attitudes between a PLWA and a client with leukemia, the AAS focuses on five modes of HIV transmission. The AAS is a series of five vignettes followed by a 16-item summated rating scale. In the vignettes, the mode of HIV transmission varied (heterosexual, homosexual, injection drug use, maternal transmission, and blood transfusion) with the remaining vignette structure unchanged. Following each vignette, the participant was asked to rate 16 declarative statements on a 7-point Likert type scale. The first 9 items on the scale were from Kelly's (1988) Prejudicial Evaluation Scale. These items represent Goffman's concept of "deservedness of care." They include such statements as Tat does not deserve this disease," "Pat is responsible for contracting AIDS," and "Pat deserves the best medical care possible". Items 10 through 16 relate to "respect and regard." They include such statements as "I respect Pat the way I respect other patients" and "I am comfortable caring for Pat." High scores represent more stigmatizing attitudes, less respect and regard, and less deservedness of care. To control for response bias the order of the vignettes was varied and there were an equal number of positively and negatively worded declarative statements. The PLWA, Pat, was not identified as being either male or female, to maintain the focus of the vignette on the mode of HIV transmission, rather than the PLWA gender.
The AIDS Knowledge Scale (AKS) consisted of 15 true/false questions which covered general aspects of AIDS knowledge. The AKS, adapted from the Questionnaire on AIDS (Lawrence & Lawrence, 1989) was updated using the AIDS Survey (Dawson, 1990). Scores were calculated by summing the number of correct responses and converting to a percentage score.
Coefficient alphas for the five AAS vignettes ranged from .80 to .86. Reliability coefficients of the subscales were .65 to .78 for "deservedness of care" and .74 to .83 for "respect and regard". The data were analyzed using repeated measures ANOVA on the AAS scale score and the two subscales.
Repeated measures ANOVA demonstrated a significant difference (F=136.24, p<.001) in stigma scores among the vignettes. Post hoc teste demonstrated a significant difference (P<-05) in stigma scores for each of the five modes of transmission. Overall, the baby who contracted AIDS via maternal transmission (mean= 28.51) had the lowest overall stigma scores, followed by the PLWA who contracted AIDS via a blood transfusion (mean= 28.76). For sexual transmission the scores were more stigmatizing, but were essentially the same for heterosexual (mean= 36.59) and homosexual transmission (mean=36.24). The PLWA with the highest stigma scores was the person who contracted AIDS via injection drug use (mean=41.08).
Analysis demonstrated significant differences in deservedness of care (F=79.82, p<.001) between the modes of transmission, except for maternal transmission and blood transfusion (t=-.50,p=.621). The baby who contracted AIDS through maternal transmission (mean=14.49) and the PLWA with leukemia who contracted HIV through a blood transfusion (mean= 14.63) were identified as the most deserving of care. The PLWA who contracted AIDS through either homosexual (mean=20.17) or heterosexual (mean= 21.15) transmission were considered to be less deserving of care than the injection drug user (mean= 17.41).
Repeated measures ANOVA demonstrated significant differences in respect and regard (F= 169.29, p<.001) between the vignettes. Like the deservedness of care results, there were significant differences in respect and regard between the modes of transmission, except for maternal transmission (mean=14.03) and blood transfusion (mean=14.05: t=- .49, p=.874). Homosexual transmission (mean=16.05) received less respect and regard than heterosexual (mean=15.49) transmission. Viewed with the least respect and regard was the PLWA who contracted HIV through injection drug use (mean=23.52).
A common concern among HIV-positive clients is that they are blamed for contracting EtTVZATDS. The findings of this study support the position that mode of transmission does influence nursing students' attitudes toward PLWAs. The baby who contracted HIV through maternal transmission and the person with leukemia who contracted HIV through a blood transfusion were perceived more positively than those who contracted the disease through injection drug use or sexual transmission. These differences may reflect a view of maternal and transfusion transmissions as uncontrollable by the PLWA, and indicates that some PLWAs may be viewed as "innocent victims" of the disease.
This study suggests that nursing students may assess not only mode of transmission, but also the occurrence of unsafe behaviors. In the vignettes portraying sexual transmission and injection drug transmission, the stigma scores were significantly higher. In addition, these three PLWAs were viewed with less respect and regard and as less deserving of care than were the baby and the leukemic PLWA. These findings are congruent with those of Cole and Slocumb (1993; 1994) who found that nurses had more negative attitudes toward a patient who acquired the virus through sharing needles than through a blood transfusion. These results are also consistent with Goffman's theory of stigma. Goffinan (1963) suggests that those who are perceived as different are more likely to be stigmatized. These findings have been supported by Siminoff, Erlen, and Lidz (1991, p. 265) who state "although some HIV-infected patients are children who were infected perinatally, and others acquire the disease through transfusion, the overwhelming majority are persons already regarded as socially deviant, as being outside the social order."
Findings in this study suggest that there are no significant differences in stigma attitudes between hetereosexual and homosexual PLWAs. These results may reflect a change in perspective that identifies unsafe sexual practice, rather than sexual orientation, as the important factor. In these vignettes, the heterosexual had several sexual partners and the homosexual had been in a monogamous relationship. Viewing the injection drug user with the least respect and regard is consistent with findings of others (Breault &. Polifroni, 1992; Cole & Slocumb, 1993). In interviews with sixteen nurses, Breault and Polifroni (1992) found that injection drug users and prostitutes were viewed more negatively than homosexuals and as being at least partly responsible for contracting HIV. These attitudes may also reflect the view of social deviance described by Siminoff, Erlen, and Lidz (1991).
In spite of the belief that behavior is volitional, subjects' responses to vignettes cannot be assumed to be identical to the actual situation (Lanza & Cariño, 1990). It is for this reason that generalizing findings from the vignettes to the actual clinical situation must remain tentative. However, the findings of this study have implications for understanding nursing students' attitudes toward the delivery of care to patients who are perceived as "different," such as those from other cultures, those with other contagious diseases, and those who are perceived to have some responsibility for their disease or condition. Further studies could explore these variables. For example, a future study might test Goffman's model by examining stigmatization associated with non-HIV disease proceeses which have modifiable risk factors, such as COPD or cardiac clients who smoke, the noncompliant diabetic, or the alcoholic with cirrhosis.
A limitation of this study is the homogeneity of the sample and the low incidence of AIDS in this geographic area. Oklahoma has 6.8 per 100,000 AIDS cases compared to a national rate of 17.4 (Oklahoma State Department of Health, 1993). A multi-site study of schools located in geographic regions where the incidence of HIV/AIDS is much higher would be helpful in determining regional variations in responses. A longitudinal study would be beneficial in addressing the effects of professional education and beginning a professional career on attitudes and intention to provide care to PLWAs.
Implications for Nursing Education
Cole and Slocumb (1994) found that comfort in performing behaviors was the only significant predictor of intention to provide care for PLWAs. An adaptation of Cole and Slocumb's (1994) study using students as the sample group could provide valuable information about the possible relationship of degree of comfort and stigmatizing attitudes toward PLWAs.
Knowledge alone is inadequate in changing attitudes. Nursing curriculum needs to incorporate affective learning, as well as cognitive and psychomotor, activities. In addition, students need role models which demonstrate acceptance and caring behaviors toward PLWAs. One wonders if nursing education programs which plan progressively complex AIDS curriculum would help improve attitudes toward PLWAs. Completing skills on a variety of clients may help maximize the student's self-confidence with technical skills. Providing care to several clients prior to assignment to a PLWA with a history of sexual or injection drug transmission may offer opportunities for progressively more intense PLWA contact. Additionally, working side-by-side with a compassionate PLWA caregiver may provide support and model accepting behaviors. Accessing caregivers who choose to provide PLWA care would be important in implementing this strategy. Finally, incorporating the "see one, do one, teach one" adage may promote progressive involvement with a PLWA. An example of tins in an AIDS curriculum would be that the student assists another nurse with PLWA care, then provides PLWA care independently, then teaches or assists another in providing PLWA care. The ultimate outcome of this progressively intense curriculum would be to develop students who are veiling to provide care to all PLWAs, Nursing students of today are the care providers of tomorrow. As such, educators have the potential to positively influence tomorrow's practice.
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