Research Briefs Faculty Attitudes About Caring for People Living With HIV/AIDS: A Comparative Study Juan M. Leyva-Moral, PhD, MSc, RN; Karen A. Dominguez-Cancino, MPH, BSN, RN; Genesis M. Guevara-Vasquez, MSc, Lic(Est); Joan E. Edwards, PhD, RN, CNS, FAAN; and Patrick A. Palmieri, DHSc, EdS, MBA, MSN, RN, FAAN ABSTRACT (Munro et al., 2017; Wagner, Girard, McShane, Margolese, & Background: People living with HIV/AIDS (PLHIV) ex- Hart, 2017). Discriminatory behaviors and fears about contract- perience stigma and discrimination. Negative attitudes of ing the virus persist in nursing (Stringer et al., 2016; Vorasane nursing faculty about caring for PLHIV can adversely affect et al., 2017; Waluyo, Culbert, Levy, & Norr, 2015) with positive student perceptions and their nursing care. The study pur- correlations between negative attitudes toward caring for PLHIV pose was to describe nursing faculty attitudes and beliefs and advanced age, homophobia, having children, race, and re- about caring for PLHIV. Method: The HPASS (Healthcare ligion (Peate, Suominen, Välimäki, Lohrmann, & Muinonen, Provider HIV/AIDS Stigma Scale), Spanish version, was de- 2002; Stringer et al., 2016). With more caring nursing attitudes livered to nursing faculty in Colombia and Peru. Results: and increased understanding about the virus and the disease, The HPASS was completed by 98 nursing faculty. The overall PLHIV can be respected, nurtured, and understood (Watson, mean score was 2.41 (SD = 0.69), with subscale scores: ste- 2002). reotypes, 2.55 (SD = 0.84); discrimination, 2.28 (SD = 0.74); Nursing faculty attitudes and beliefs are important to under- and prejudices, 2.41 (SD = 0.63). Peruvian faculty had the stand as they can become part of the informal, or occult, cur- highest scores, statistically correlated with the importance riculum (Sirota, 2013; Tanner, 1992, 2004)—that is, there can of religion, whereas Colombia had the lowest. Conclusion: be implicit learning impregnated with values (Chuang et al., Nursing faculty attitudes toward PLHIV were slightly posi- 2010; Thompson, Emrich, & Moore, 2003). Since the earliest tive in Colombia to slightly negative in Peru; however, both study examining student and faculty attitudes about caring for countries had negative stereotypes. Knowledge deficiencies PLHIV (Mueller, Cerny, Amundson, & Waldron, 1992), there about HIV persist and attitudes appear to be influenced by have been fewer than 20 additional studies reported in the lit- culture and religion. [J Nurs Educ. 2019;58(12):712-717.] erature (PubMed® and SciELO searches). However, the results of the few studies often report only students in small local sam- ples using a validated, although outdated, instrument (Bektas & D espite advancements in scientific knowledge and clini- Kulakaç, 2007; Earl, 2010; Li, Scott, & Li, 2008; Lohrmann et cal management strategies since the first reported case al., 2000; Röndahl, Innala, & Carlsson, 2003; Suominen, Laak- of AIDS (Centers for Disease Control and Prevention, konen, & Lioznov, 2015). 1982), people living with HIV/AIDS (PLHIV) continue to ex- In the context of PLHIV in South America, Colombia (Red perience stigmatization and discrimination throughout the world Colombiana de Personas que Viven con VIH, 2015) and Peru Dr. Leyva-Moral is Senior Lecturer, Department of Nursing, Universitat Autonoma de Barcelona, Barcelona, Spain; Dr. Edwards is Professor and Director, Center for Global Nursing, Texas Woman’s University, Houston, Texas; Ms. Dominguez-Cancino is Research Fellow, Center for Health Sciences Research, Universidad María Auxiliadora, Lima, Ms. Guevara-Vasquez is Biomedical Statistician, Research Department, Hospital Regional Lambayeque, Chiclayo, Lambayeque, and Dr. Palmieri is Vice Chancellor for Research, Universidad Norbert Wiener, Lima, Peru. © 2019 Leyva-Moral, Dominguez-Cancino, Guevara-Vasquez, et al.; licensee SLACK Incorporated. This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 International (https://creativecommons.org/licenses/by/4.0). This license allows users to copy and distribute, to remix, transform, and build upon the article, for any purpose, even commercially, provided the author is attributed and is not represented as endorsing the use made of the work. This project was partially funded by a research dissemination grant from the Vicerrectorado de Investigación at the Universidad Norbert Wiener (Lima, Peru). The authors thank colleagues Dr. Sandra. K. Cesario, Prof. Doris B. Gonzales-Carhuajulca, Dr. M.I. Lalinde, Ms. Nataly, Membrillo-Pillpe, Prof. P. Piscoya- Angeles, and Dr. G. A. Sandoval-Peña for their assistance with the study design or data collection. The authors have disclosed no potential conflicts of interest, financial or otherwise. Address correspondence to Patrick A. Palmieri, DHSc, EdS, MBA, MSN, RN, FAAN, Vice Chancellor for Research, Universidad Norbert Wiener, Av. Areq- uipa 444, Lima, 15046, Peru; e-mail: patrick.palmieri@globalnursing.org. Received: December 26, 2018; Accepted: September 4, 2019 doi:10.3928/01484834-20191120-06 712 (Consorcio de Organizaciones de Personas con VIH en el Peru, bardier, & Beaton, 1993; Sousa & Rojjanasrirat, 2011). The 2018) report higher than average stigma indexes, which results experts included 12 bilingual nursing faculty from Chile, Co- in widespread discrimination. Furthermore, the health system lombia, and Peru. contributes to the stigmatization of PLHIV in Colombia (Djel- louli & Quevedo-Gómez, 2015; Ritterbusch, Correa-Salazar, & Data Analysis Correa, 2018) and Peru (Perez-Brumer et al., 2017; Valenzu- Descriptive statistics were performed for all variables in ela et al., 2015) through discriminatory and prejudicial conduct the two-country sample, as well as for each individual coun- of health care professionals (Avert, 2019; Cianelli, Ferrer, & try. Bivariate inferential statistics were performed to compare McElmurry, 2008), which negatively influences their quality of the total scale score, each subscale, and the sociodemographic care (Piñeirúa et al., 2015). Despite being recognized, the stig- variables by country. As a pilot study, the threshold for signifi- ma and discrimination within the health systems have largely cance was set at 0.09 (Conn, Algase, Rawl, Zerwic, & Wyman, been ignored (Cáceres & Mendoza, 2009) as an institutional- 2010; Hertzog, 2008). An analysis was also performed to ex- ized reality (Valencia-Garcia, Rao, Strick, & Simoni, 2017). As amine the correlation between sociodemographic variables potential change agents within the context of health systems, and the HPASS-ESP scores (scale and subscales). Parametric the objective of this study was to understand Colombian and and non-parametric statistics were used (McCullagh & Nelder, Peruvian nursing faculty attitudes and beliefs about caring for 1989; Polit & Beck, 2017; Siegel & Castellan, 1988) with a cor- PLHIV. relation analysis to measure the direction and strength of poten- tial associations across the three considered subscales (Altman, METHOD 1991). The data were organized in an Excel® spreadsheet and analyzed with Stata® 14.0. The study is reported according to Study Design and Population the STROBE (Strengthening The Reporting of OBservational This pilot study represents the South America data from an Studies in Epidemiology), following the minimum reporting ongoing multicenter observational study with nonrandomized requirements for cross-sectional studies (von Elm et al., 2014). electronic sampling. Data were collected from four schools of nursing in Colombia and Peru using an online version of the RESULTS Healthcare Provider HIV/AIDS Stigma Scale, or HPASS (Wag- ner, Hart, McShane, Margolese, & Girard, 2014), from January The total of 98 nursing faculty from Peru (N = 57) and Co- to July 2017. The HPASS was sent to university faculty e-mails lombia (N = 41) responded to the HPASS-ESP. The participant on record (estimated response rate = 52%). The inclusion crite- median age was 44 years (interquartile range [IQR] = 37 to 53), ria were all nursing faculty with an e-mail on record, whereas the majority identified as female (n = 80, 81.6%), with a median all others were excluded. The study was approved by the univer- teaching experience of 9.5 years (IQR = 5.0 to 15), and 93.9% sity institutional review board. completed postgraduate studies. Participants primarily taught in an undergraduate program (n = 85, 86.7%), most self-identified Instruments and Measures as Catholic (n = 87, 88.8%), and most indicated religion as im- The validated 30-item HPASS (Wagner et al., 2014) mea- portant to very important in their lives (n = 79, 80.6%). sures stigma with three dimensions: discrimination (six items), Overall, the mean scale score was 80.0 (SD = 22.9); the sub- prejudice (13 items), and stereotype (11 items). The internal scale mean scores were 12 (IQR = 9.0 to 16) for discrimina- consistency and test–retest reliability for the scale (Cronbach’s tion, 31 (IQR = 21 to 40) for prejudices, and 35.2 (SD = 10.3) alpha between .88 and .94) and the three individual subscales for stereotypes. The mean scale score was 68.6 (SD = 20.6) for (Cronbach’s alpha between .80 and .93) are excellent (Wagner Colombia and 88.2 (SD = 21.1) for Peru. The country subscale et al., 2014; Xie et al., 2019). The 6-point Likert scale, rang- scores included the following: discrimination of 11 (IQR = 8 to ing from complete disagreement (1) to complete agreement (6), 15) for Colombia and 14 (IQR = 10 to 18) for Peru; prejudices in response to statements about PLHIV-eliminated ambiguous of 24 (IQR = 19 to 35) for Colombia and 36 (IQR = 28 to 41) for midline responses to provide an “accurate picture of the atti- Peru; and stereotypes of 29.9 (SD = 9.7) for Colombia and 39.1 tudes and beliefs” held by participants (Wagner et al., 2014, p. (SD = 9.0) for Peru. When comparing the countries, the scores 2405). The scale midpoint score is 105, ranging between 30 and were statistically significant for the sigma scale (p < .001) and 180. Similarly, the subscale midpoints are 21 for discrimination each of the three subscales, discrimination (p = .030), preju- (range = 6 to 36), 45.5 for prejudice (range = 13 to 78), and dices (p = .006), and stereotypes (p < .001). 39 for stereotype (range = 11 to 66). Higher scale scores from In the analysis of the sociodemographic variables, total scale the midpoint are associated with more stigma (similar for sub- score, and subscale scores, statistically significant associations scales) and lower scores with less stigma. were found between the level of education and the scale (p = .037) and the discrimination subscale (p = .019). For educa- HPASS-ESP tion level and the scale score, participants with undergraduate A Spanish version of the scale (HPASS-ESP), for cross- education (80.5, SD = 22.6) scored higher than those with post- cultural research in South America, was produced through a graduate education (56.3, SD = 16.8). In the case of the discrim- rigorous process including forward and reverse translations, ination subscale, participants with undergraduate education (12, expert item evaluations, subscale analysis, and adaptation for IQR = 9.0 to 16) also scored higher than participants with post- equivalence in content, context, and culture (Guillemin, Bom- graduate education (6.5, IQR = 6.0 to 9.5). In the analyses by Journal of Nursing Education • Vol. 58, No. 12, 2019 713 country, the significance remained for the discrimination sub- 2008; Quevedo-Gómez, Krumeich, Abadía-Barrero, Pastrana- scale for Peruvian participants (p = .0316), and the scores for Salcedo, & van den Borne, 2012). In the Latino community, participants with undergraduate education (2, IQR = 1.5 to 2.7) ideas about machismo seem to contribute to discrimination were higher than those with postgraduate education (1, IQR = against women and gay men, resulting in enhanced homopho- 1.1 to 1.6). bia and increased sexual coercion (Marín, 2003). As the years of teaching experience had different distribu- In addition, the higher scale score in Peru might be associ- tions (normal for Colombia and not normal for Peru), the analy- ated with the machismo prevailing in the Peruvian health sector sis was performed separately. A significant statistical difference (Palmieri, 2017) and therefore the discrimination experienced was found with years of experience in the case of Peru for total by the collective LGBTQ community. Other investigations have scale score (Spearman’s rho = 0.32; p = .014), and the preju- found correlations associated with stigma and discrimination dice (Spearman’s rho = 0.39; p = .003), stereotype (Spearman’s with religion (Kinyanda et al., 2012; Leyva-Moral et al., 2017; rho = 0.24; p = .07), and discrimination subscales (Spearman’s Stringer et al., 2016), noted to be a significant difference be- rho = 0.23; p = .09). However, none of these associations were tween Peru and Colombia in this study. In particular, the higher significant for Colombia. In the analysis of religious importance scores in Peru might be explained by conservative Catholic for the two countries, a significant difference was found in the traditions. However, these differences could also result from scale score and stereotype subscale (Peru = 2.91, SD = 0.10; the sampling strategy and variability of sociocultural contexts Colombia = 2.25, SD = 0.11; p < .0001); no relationship was in which participants share cultural meanings associated with found with the other subscales. sexuality and HIV but not with religious affiliation. There were also significant correlations between the total Positive attitudes are related to increased caring behaviors scale score and each of the three subscales (discrimination: r = (Dyson, 1996; Watson, 2008). Nursing education has long .73, < .001; prejudice: r = .91, <0.001; and stereotype: r = .83, played an important role in the development of caring attitudes p < .001). Additionally, there were correlations observed be- (Eron, 1955), the acquisition of knowledge (Benner, 1982), and tween all the subscales (stereotype and prejudice: r = .57, p < the advancement of caring behaviors (Bevis & Watson, 1989). .001; stereotype and discrimination: r = .38, p < .001; and dis- For nurses, caring is “the moral ideal of nursing whereby the crimination and prejudice: r = .68, p < .001). Finally, in terms of end is protection, enhancement, and preservation of human dig- stereotypes and false beliefs, four item responses scored greater nity” (Watson, 1985, p. 29). However, negative faculty attitudes than 4 of 5, indicating participants from both countries gener- and incorrect beliefs about caring for PLHIV can adversely ally believe “if people act responsibly, they will not contract influence the attitudes of students and the care they provide. HIV” and HIV positive patients “have engaged in risky activi- This can be partly explained in relationship to their comfort ties despite knowing these risks” and “should accept responsi- teaching specialized content about populations. For example, bility for acquiring the virus.” They were also “worried about Sirota (2013) described “a long skew toward negative attitudes” contracting HIV from HIV+ patients.” (p. 222) for more than half of the nursing faculty (n = 733) in a study regarding homosexuality. As less than 30% of faculty DISCUSSION were prepared to teach students about homosexuality, almost 90% indicated a “sense of ignorance about what content to The findings from this study indicate nursing faculty atti- teach and how to teach it” (p. 225). The implication is that fac- tudes about caring for PLHIV are neutral to slightly positive; ulty are not comfortable teaching what they do not understand. however, there are notable differences between Colombia and Faculty caring behaviors can positively influence the car- Peru, as well as some common areas for improvement. The item ing behaviors of their students (Labrague, McEnroe-Petitte, analysis indicates a persistent presence of false myths and lack Papathanasiou, Edet, & Arulappan, 2015). As such, developing of knowledge about HIV/AIDS, also reported in other studies faculty education about caring for PLHIV is a viable strategy to (Leyva et al., 2017). The analysis indicates both countries dem- advance positive caring attitudes in students. In general, univer- onstrate stereotypical attitudes and beliefs that can adversely sity faculty need to develop critical and constructive approaches impact patient care. However, despite concerns about contract- to teaching students about HIV/AIDS (Camillo, Maiorino, & ing the virus, the participants were not hesitant to “come into Chaves, 2013), including sharing personal experiences from physical contact with HIV+ patients” and believe there is no PLHIV in the classroom. In this regard, expert patient illness “right to refuse to treat HIV+ patients to protect” themselves. narratives have been reported to be an effective teaching meth- Overall, the faculty results observed in the two countries od for nursing students (Feijoo-Cid, Moriña, Gómez-Ibáñez, & are slightly higher than the scores from other countries (e.g., Leyva-Moral, 2017) to develop cultural sensitivity, respect, and Spain and Germany) in terms of the overall stigma score and trust in others (Davidson, 2005). Similarly, when PLHIV are stereotype score. This finding might be attributed to the high included as simulated patients, HIV-related stigma decreases HIV-related stigma reported in Latin America (Johnson et al., and comfort in providing care increases (Jaworsky et al., 2017). 2015), including overt discrimination experienced by lesbian, More favorable attitudes about caring for HIV-infected preg- gay, transgender, and bisexual people (i.e., the LGBTQ com- nant women among certified nurse practitioners compared with munity) (Barrientos, 2016). In Latin America, there is a close RNs (Farley et al., 2014). Finally, positive empathetic attitudes relationship between machismo and the meanings associ- (r = .36, p < .001) were negatively correlated with avoidant at- ated with sexuality (Marín, 2003), and therefore attributed to titudes (r = –.34, p < .001) in nurses working in HIV clinics sexually transmitted infections such as HIV (Cianelli et al., compared with those working in general clinics (Hamama et al., 714 Barrientos, J. (2016). Situación social y legal de gays, lesbianas y per- 2014). Education and daily interactions between the providers sonas transgénero y la discriminación contra estas poblaciones en and PLHIV result in more positive caring attitudes. América Latina [The social and legal status of gay men, lesbians and transgender persons, and discrimination against these populations in LIMITATIONS Latin America]. Sexualidad. Salud y Sociedad, 22, 331–354. https://doi. org/10.1590/1984-6487.sess.2016.22.15.a Bektas, H. A., & Kulakaç, O. (2007). Knowledge and attitudes of nurs- This study has three important limitations. First, this study ing students toward patients living with HIV/AIDS (PLHIV): used a self-administered instrument. According to Parahoo A Turkish perspective. AIDS Care, 19(7), 888–894. https://doi. (1997), participants might have tried to present what they be- org/10.1080/09540120701203352 PMID:17712692 lieve is a desirable image resulting in more favorable scores. Benner, P. (1982). From novice to expert. The American Journal of Nursing, 82(3), 402–407. PMID:6917683 Second, the nonrepresentative convenience samples in metro- Bevis, E. O., & Watson, J. (1989). Toward a caring curriculum: A new ped- politan areas of each country might not be representative of the agogy for nursing. New York, NY: National League for Nurses. entire country. Third, the small sample size resulting from the Cáceres, C. F., & Mendoza, W. (2009). The national response to the HIV/ intentional sampling strategy could have similarly influenced AIDS epidemic in Peru: Accomplishments and gaps—A review. Jour- nal of Acquired Immune Deficiency Syndromes, 51(Suppl 1), S60–S66. the results. Even so, this study is the largest sample size re- https://doi.org/10.1097/QAI.0b013e3181a66208 PMID:19384104 ported in the literature for Latin America and the only study Camillo, S. O., Maiorino, F. T., & Chaves, L. C. (2013). O ensino de comparing the context of different countries. enfermagem sobre HIV/AIDS sob a ótica da cidadania. [Nursing teaching on HIV/AIDS in the perspective of citizenship]. Revista CONCLUSION Gaúcha de Enfermagem, 34(3), 117–123. https://doi.org/10.1590/ S1983-14472013000300015 PMID:24344593 Centers for Disease Control and Prevention. (1982). Update on Acquired In general, nursing faculty attitudes toward caring for Immune Deficiency Syndrome (AIDS)—United States. MMWR Weekly, PLHIV were slightly negative in Peru to slightly positive in Co- 31(37), 507-514. Retrieved from https://www.cdc.gov/mmwr/preview/ lombia, with the stereotype subscale requiring improvement in mmwrhtml/00001163.htm Chuang, A. W., Nuthalapaty, F. S., Casey, P. M., Kaczmarczyk, J. M., Cul- both countries. Myths and lack of knowledge about HIV/AIDS limore, A. J., Dalrymple, J. L., . . . Undergraduate Medical Education remain problematic and attitudes appear to be influenced by na- Committee, Association of Professors of Gynecology and Obstetrics. tionality, education, and religion. Nursing faculty need to take a (2010). To the point: Reviews in medical education-taking control of critical and constructive approach to improving HIV/AIDS edu- the hidden curriculum. American Journal of Obstetrics and Gynecol- cation, including the incorporation of real-world experiences of ogy, 203(4), 316.e1–316.e6. https://doi.org/10.1016/j.ajog.2010.04.035 PMID:20541735 PLHIV in the classroom. Cianelli, R., Ferrer, L., & McElmurry, B. J. (2008). HIV prevention and Importantly, previous research has not established the cor- low-income Chilean women: Machismo, marianismo and HIV miscon- relation between the three dimensions (discrimination, preju- ceptions. Culture, Health & Sexuality, 10(3), 297–306. Retrieved from dices, and stereotypes) among nursing faculty. In addition, this https://doi.org/https://doi.org/10.1080/13691050701861439 https://doi. org/10.1080/13691050701861439 PMID:18432428 study found a correlation between the three subscales and the Conn, V. S., Algase, D. L., Rawl, S. M., Zerwic, J. J., & Wyman, J. F. (2010). overall scale. This finding is important to justify continued re- Publishing pilot intervention work. Western Journal of Nursing Re- search with the HPASS with the goal of developing interven- search, 32(8), 994–1010. https://doi.org/10.1177/0193945910367229 tions to decrease stigma. As all the factors are related, an edu- PMID:20702685 cational activity designed to improve attitudes will impact the Consorcio de Organizaciones de Personas con VIH en el Peru. (2018). Índice de estigma y discriminación informe final: Hacia las personas three dimensions. con VIH en Peru [Index of stigma and discrimination final report: To- Additional research is necessary for three reasons. First, the wards people with HIV in Peru]. 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