Medical and dental students’ willingness to administer treatments and procedures for patients living with AIDS
1 Department of Medical Rehabilitation (Physiotherapy), University of Maiduguri, Maiduguri, Borno State, Nigeria and Dominican College Program in Physical Therapy, Orangeburg, New York, USA
2 Department of Medical Rehabilitation (Physiotherapy), University of Maiduguri, Maiduguri, Borno State, Nigeria
3 Department of Physiotherapy, University of Jos Teaching Hospital, Jos, Plateau State, Nigeria
4 Department of Physiotherapy, University of Maiduguri Teaching Hospital, Maiduguri, Borno State, Nigeria
5 Department of Oral and Maxillofacial Surgery, University of Maiduguri Teaching Hospital, Maiduguri, Borno State, Nigeria
Department of Medicine, University of
Maiduguri Teaching Hospital, Maiduguri, Borno State, Nigeria
Background. Nearly three decades after the discovery of the human immunodeficiency virus (HIV), acquired immunodeficiency syndrome (AIDS) epidemics continue to pose significant challenges to low-income countries in sub-Saharan Africa.
Objective. To assess medical and dental students’ willingness to perform specific techniques and procedures on people living with AIDS (PLWA).
Methods. A survey was done among medical and dental students (N=304) at a Nigerian University using a 21-item questionnaire that elicited responses on sociodemographic characteristics and willingness to perform specific techniques and procedures. Analysis of variance (ANOVA) and an independent t-test were used to determine the influence of sociodemographic variables. Multiple regression analyses were used to determine the predictors of willingness.
Results. The cohort of medical and dental students was willing to care for PLWA. Almost all medical students were either undecided or unwilling to perform mouth-to-mouth resuscitation. A higher proportion of dental students were either undecided or unwilling to assist during surgery, tooth extractions and other procedures they considered to be invasive. More medical than dental students were willing to carry out surgical procedures. Previous personal encounters with AIDS patients, religion, and satisfaction with instructions influenced medical and dental students’ willingness to care for PLWA, while knowing a family member living with AIDS (R2=0.22, p<0.001) was the strongest predictor of willingness to care for PLWA.
Conclusion. Extensive use of
clinical clerkships and exposure through direct experience are
viable strategies necessary for optimising and enhancing medical
and dental students’ dispositions to perform procedures and care
Nearly three decades after the discovery of the human immunodeficiency virus (HIV), acquired immunodeficiency syndrome (AIDS) epidemics continue to pose significant challenges to low-income countries in sub-Saharan Africa and to impact on the attrition rate, level of motivation, professional practices and absenteeism from work of healthcare workers.1 About 90% of HIV infections among healthcare workers occur in developing countries, where occupational safety procedures are often neglected.2 While a cure and an effective vaccine have not been found for AIDS, many people living with HIV/AIDS in Nigeria are still being denied access to treatment.3-5
It is a generally believed that, given the widespread stigmatisation of HIV/AIDS patients, even among healthcare workers, including doctors and dentists,6 , 7 the behaviour towards people living with AIDS (PLWA) continues to play a vital role in care and treatment. Fear of contagion, concerns for safety, poor attitude and unwillingness to provide care to PLWA among healthcare personnel and students remain widespread.7 , 8 Consequently, students’ knowledge and the attitude of healthcare professionals and students towards PLWA continue to be of interest. Healthcare workers’ attitude remains a core reason why many Nigerians living with HIV/AIDS are denied access to treatment.[5,9-12]
A previous study has shown that medical students in the USA believed that their education had not prepared them to safely treat PLWA,8 and Taiwanese dental students were found to be more willing to treat hepatitis B virus (HBV)- and hepatitis C virus (HCV)-infected patients than those with HIV infection.13 Recently, Sudanese dental students felt that they were not well prepared for their future task of treating patients with HIV/AIDS.14 Another study showed that on average 60% of Nigerian dental students were willing to care for PLWA.5 , 9 A widespread poor attitude and disposition among students may continue after completion of their studies.
The goal of any professional education is to produce practitioners with competencies in the technical and non-technical aspects of practice. Technical competence is the ability to perform a specific task in a given situation, while non-technical competence involves the nuances and understanding that enable a practitioner to communicate effectively with patients and other healthcare professionals and select appropriate treatment and procedures.15 Therefore, a preferred professional programme should prepare students with the necessary cognitive, psychomotor and affective skills, including a positive disposition to provide care and perform procedures on patients with any condition, including transmissible diseases such as AIDS.
It has been shown that a willingness to treat patients with HIV/AIDS may be related to knowledge of the disease process, recognition of its manifestations, and understanding of its modes of transmission.16 However, knowledge alone may not be sufficient to guarantee optimal care for patients with stigma-associated conditions such as AIDS. As contributors to healthcare, students’ willingness to use specific procedures allows for the identification of areas of concern that can be focused on during training to optimise behaviour in managing PLWA or any other contagious disease.
The literature shows that previous studies indirectly
investigated medical and dental students’ willingness to care
for PLWA using global attitudinal items. None of these studies
utilised clinical scenarios to elicit willingness responses.5
a few studies assessed willingness towards procedures such as
10 Therefore, the aim of our
study was to assess medical and dental students’ willingness to
perform specific common procedures during medical and dental
care of PLWA.
Materials and methods
Participants in this study were medical and dental students in
the last two years of their professional training at the College
of Medical Sciences, University of Maiduguri, Borno
State, Nigeria,who were willing to participate. A total of
304/385 students surveyed returned their questionnaires,
translating to a response rate of 78.9%.
A two-part 21-item questionnaire designed by Held,18 and adapted by Balogun et al.,19 was used in this study. Part 1 elicited sociodemographic information on previous experience with PLWA and previous AIDS educational instructions. Part 2 elicited students’ willingness to perform five selected techniques or procedures or care unique to their discipline on a 5-point Likert scale, ranging from strongly willing (1) to strongly unwilling (5). All five items on the subscale were worded positively to minimise the inherent contamination and response shift bias due to social desirability phenomena.20 The minimum and maximum scores for the subscale were 5 and 25, respectively, and the higher the subjects’ total score, the less the willingness to provide services for PLWA. Held18 and Balogun et al. 19 reported reliability coefficients of 0.80 and 0.76, respectively, for the willingness subscale of the instrument. In a separate Nigerian study, Oyeyemi et al.21 reported correlation coefficients ranging between 0.72 and 0.88 for the subscales of the instrument, including the willingness subscale.
The willingness subscale for medical students was adapted
from a scale used to assess physicians’ willingness in a
previous study,7 while the willingness
subscale for dental students was developed by the authors in
collaboration with experienced dental practitioners in a
teaching hospital. The content of the final document was
judged to have face validity by two lecturers in the
A sample of convenience comprising medical and dental students in the College of Medical Sciences, University of Maiduguri, participated in this survey. The questionnaire was handed to the students in their lecture halls at the University of Maiduguri Teaching Hospital after lectures on topics unrelated to AIDS.
Prior to the study, ethical approval was obtained from the
University of Maiduguri Teaching Hospital Ethical Committee.
Anonymity was assured, while participants were also informed in
a cover letter that completion and submission of the survey form
Using SPSS version 16, descriptive statistics of means and
percentages were computed and analysis of variance (ANOVA) and
independent t-tests were used to
determine the influence of sociodemographic variables on
willingness. Multiple regression analyses determined the
predictors of willingness to perform procedures. Proportional
differences were explored using chi statistics. Differences were
considered significant at an alpha level of 0.05.
The students’ mean age was 24.9 (SD±2.6) years. A total of 188 (61.8%) were male, 116 (38.1%) were female, and 218 (71.7%) did not personally know anyone living with HIV/AIDS. Approximately 154 (51%) had previously been asked to provide care to PLWA, 182 (59.9%) had experience in caring for PLWA, and 300 (98.7%) had received instructions on HIV/AIDS. Furthermore, 270 (88.8%) would care for PLWA if asked to do so. Medical students tended to have been asked to care for PLWA more frequently (chi statistic = 12.15; p<0.001) and had more previous encounters with PLWA (chi statistic = 85.25; p<0.001) than dental students (Table 1).
Willingness to care for PLWA
The majority of medical students were willing to perform
75.3%) and insert arterial lines (n=17;
74.0%), while 143 (61.9%) were not willing to perform
mouth-to-mouth resuscitation on PLWA. A total of 126 (55%)
medical students were willing to perform vaginal examinations,
while 160 (69.2%) would assist with surgery for PLWA. Among
dental students, 58 (78.8%) were willing to perform impression
casting, while almost half (n=35;
48%) were unwilling to assist with an operation. Only about
60% were willing to perform scaling and polishing (n=43; 59.6%,), and 25 (34.6%) and
34 (46.2%) were unwilling to perform tooth extractions and
root canal therapy, respectively (Table 2).
The students’ mean overall willingness score was 13.4±4.0 out of a possible total score of 25. Overall, medical students were either willing or undecided on responses with regard to performing venepuncture (2.2±0.9), inserting arterial lines (2.3±1.0), and performing surgery (2.4±1.1), while they were more undecided than willing to perform vaginal examinations (2.7±1.1). However, these students were mostly unwilling to perform mouth-to-mouth resuscitation on PLWA (3.9±1.1). Overall, dental students were willing to do impression casting (1.9±0.9) and willing or undecided to perform scaling and polishing procedures (2.6±1.2).They were mostly undecided about performing tooth extractions (2.9±1.1) and root canal therapy (3.2±1.2) and in assisting during operations (3.1±1.3).
Medical students’ willingness was significantly lower (p<0.001) to perform mouth-to-mouth
resuscitation compared with other procedures. For dental
students, there was no significant difference (p>0.05) between willingness to do
scaling and polishing and tooth extractions; however, there was
a significant difference between these and other procedures.
Also, willingness to perform impression casting was
significantly better (p<0.05)
than willingness to carry out other procedures. Furthermore,
there was no significant difference (p>0.05)
with regard to willingness to assist with surgery and perform
root canal therapy. There was a significant difference (p<0.05) between carrying out these
tasks and others such as scaling and polishing, tooth extraction
and impression casting (Table 2).
Influence of sociodemographic and previous encounters on willingness to care for PLWA
The effect of sociodemographics on overall willingness score in each discipline was assessed. Among medical students, there was a significant difference in willingness by gender, with males being more willing to care for PLWA (p<0.05). There was also a significant difference (p<0.05) in willingness by religious affiliation, as students who subscribed to the Christian faith were more willing to care for PLWA than their Muslim counterparts (mean score: Muslims = 13.08; Christians = 14.02). Moreover, students who answered ‘No’ to the question ‘Have you ever refused to care for PLWA?’ were more willing to care for PLWA (p<0.05) than those who answered ‘Yes’ (mean = 15.61 v. 13.37).
Among dental students, there was no significant difference by gender and religion (p>0.05). However, students who answered ‘Yes’ to the question ‘Have you ever been asked to care for PLWA?’ were more willing to care for PLWA (p<0.05) than those who answered ‘No’ (mean = 13.73 v. 11.21). Students who know a family member with AIDS were more willing to care for PLWA (p<0.05) than those who did not (11.9 v. 15.2).
Across both disciplines, those with previous experience
of caring for AIDS patients were more willing to care for PLWA
than their counterparts who had not had any previous contact
with such patients (p<0.001).
When asked, ‘Will you be willing to care for PLWA?’ students
who answered positively were more willing to care for PLWA (p<0.05; mean = 13.4 v. 15.3
mean = 12.2 v. 16.8 (dental)) than those who answered
negatively. Students who chose hospital practice as their
long-term goal were more willing to care for PLWA (p<0.05; F=2.75 (medical);
F=2.98 (dental)) than those who would prefer teaching. Those
who were satisfied with instructions on AIDS were more willing
to care for PLWA than those who were somewhat dissatisfied or
not satisfied (p<0.05;
F=3.78 (medical); F=2.91 (dental)). There was no significant
difference in willingness by clinical year (p>0.05). In the final
regression equation, knowing a family member living with AIDS
was by far the strongest predictor of willingness (R2=0.22;
in descending order by refusal to care for PLWA (R2=0.20; p<0.001) and long-term goal
The majority (88.8%) of medical and dental students in this study were generally willing to care for PLWA if asked to do so. The proportion of dental students who were willing to provide oral health services to PLWA (88.8%) exceeds that of Nigerian dental students in previous studies in which only about 60% expressed willingness.5 , 9 The proportion is also higher than or comparable to Nigerian dentists in two previous studies in which 63.6% and 78.4% of respondents, respectively, were willing to provide care to PLWA.22 , 23 This proportion can almost be compared with that of dental students in the USA (83%),24 while it exceeded that in Taiwan (49%),13 India (75%),11 Iraq (75.5%)25 and Jordan (73.7%).26
In the present study, the proportion of medical students (90.5%) who were willing to care for PLWA if asked is higher than the 85% reported by Tibdewal et al. 11 among Indian medical students. It is higher than that reported among Nigerian doctors (82%), in whom willingness was assessed using the same scale as in the present study.7 Only 16.0% of medical students were willing to perform mouth-to-mouth resuscitation on PLWA compared with 24%10 and 72%8 reported among medical students in India and the USA, respectively.
The proportion of medical students willing to assist with surgery is comparable to the 60% reported by Mohsin et al., 10 but slightly lower than the 71% reported by Kermode et al. 2 in a study among healthcare workers in rural India. Overall, medical students were more willing to perform non-invasive procedures, such as venepuncture, and insert arterial lines, than performing vaginal examinations, which is considered to be an invasive procedure.
Dental students were also more willing to carry out less invasive procedures such as impression casting and scaling and polishing than root canal therapy and tooth extractions, which are considered to be invasive. This finding is consistent with that of Mohsin et al., 10 who reported an unwillingness among medical students to carry out invasive procedures involving AIDS patients.
Medical students were more willing to assist with surgery than dental students (69.2% v. 38.5%), probably because more of the former had previous experience of caring for PLWA (63.2% v. 49.3%). The influence of religious affiliation on willingness to perform procedures is in agreement with the findings in one previous study that reported a more positive attitude among Catholics than Jewish students.19 Previous experience of working with AIDS patients was also associated with an increased willingness to care for PLWA, a finding consistent with a recent report among Nigerians doctors,7 but at variance with one previous study on allied health professional students.8
Limitations of this study
This single-centre study has limitations in terms of the
generalisability of the findings. Its results should be
interpreted with caution because the students’ responses could
have been affected by social desirability phenomena,18 in which
the students answered questions based on what they presumed is
socially desirable. Furthermore, the apparent disparity between
students’ responses is evidenced by the overwhelming majority of
them indicating that they would care for PLWA if asked and their
overall disposition that rates were undecided in 3 of the 5
procedures. This highlights the difficulty in predicting
behaviour, and therefore the findings of this study should be
The cohorts of medical and dental students in the present study
were willing to care for PLWA if asked, but may be reluctant
with regard to performing some common procedures on PLWA. These
students were more willing to carry out less invasive procedures
than those which they considered to be invasive ones. Previous
personal encounters with PLWA, satisfaction with instructions
and answering ‘Yes’ to the question ‘Are you willing to care for
PLWA?’ influence students’ willingness to perform procedures on
PLWA. Preferred practice settings, previous refusal to care for
PLWA when asked, and knowing a family member or some other PLWA
combined, predict willingness. This study suggests that
extensive use of clinical clerkships and exposure through direct
experience can enhance students’ disposition to perform
procedures on PLWA.
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