Discussion
The current study provides insights about knowledge and attitudes of 144
healthcare workers, peer educators, outreach workers and volunteers
working in HIV testing centers in Lebanon in regards to HIV and STIs.
Knowledge is a latent concept difficult to properly measure. Using
individual questionnaire items to measure the effectiveness of the
intervention would not only carry considerable imprecisions, but also
make it difficult to accurately assess the overall magnitude and
sometimes even the direction of this impact. The construction of scores
using multiple items intended to capture the greatest amount of
variability across the different knowledge scales while limiting the
imprecision. Although the pre-intervention rates show a relatively large
gap of knowledge and misconceptions regarding modes of transmission of
the infection and preventions, the post-intervention rates were higher
with statistical significance and confirm the efficacy of the
intervention. Thus, the main objective of this report was achieved and
the intervention among healthcare workers was successful.
That being said, there are some interesting additional observations to
be noted from this study. Across both urban and rural samples,
participants were more knowledgeable at baseline with STI facts than
they were with particular HIV facts (56.8% vs 41.2%, respectively).
Although both sets of information were acquired at different rates
(knowledge rise: 29.7% STI vs 37.5% HIV), participants had higher
overall post-intervention knowledge about STI than they did HIV (86.5%
vs. 78.7%, respectively). This finding consolidates the value of these
training sessions and highlights the importance of repetition and the
use of innovative learning approaches, especially that the disease
prognosis of HIV carries far more consequences than any other STI.
The results indicate that rural Beqaa participants absorbed a greater
amount of information, meaning the intervention was therefore more
impactful among this subsample. This was particularly true for HIV and
STI knowledge where participant knowledge increased from poor to very
significant rates. While this was also true for stigma knowledge when
examining the overall sample, a closer look showed that Beqaa
participants displayed a great resistance to this information. The
authors postulate that this was not the result of a difficulty in
assimilating information, rather a resistance to accept and translate
this particular information into words in a setting strongly driven by
cultural and religious beliefs. Some studies have provided evidence for
a robust relationship between knowledge and level of
acceptance11 while others found no evidence of direct
relationships even when learning gains have been
substantiated12. Further qualitative work should
explore this particular distinction across the sexual health context.
HIV/AIDS-related stigma and discrimination among health care workers is
one of the most important factors of HIV expansion. It discourages
people from seeking care or being tested for HIV, thus reducing access
to HIV/AIDS prevention. Further efforts and interventions should address
this issue among service providers to reach higher scores.
Similar studies have been conducted in Lebanon but show old data. In
1993, a total of 350 nurses were interviewed to assess their knowledge,
attitudes, beliefs and practices regarding HIV/AIDS13.
Findings revealed that the majority of nurses were aware of modes of HIV
transmission and 80% mentioned condom use as a protective measure. On
the other hand, misconceptions were highly prevalent and negative
attitudes towards MSM were expressed. Among the questioned nurses, only
46% were willing to care for an HIV patient and 50%
encouraged isolating patients with HIV in special wards. A second study
conducted in 2005 among laboratory workers revealed that 49% of the
assessed laboratories lacked the appropriate equipment to dispose of
needles and other sharp objects14. No previous studies
have assessed HIV and STIs knowledge in healthcare workers who deal on
the ground with general and key populations.
Knowledge among the MSM and sex workers (SW) communities was studied in
20182. These communities are served by the centers’
staffs surveyed in this report. Thus, a comparison between the service
providers and the service recipients might show some insights in lack of
data settings. A comparison between some of the indicators that exist in
the mentioned report and in the current report show higher knowledge in
healthcare workers compared to the 2 communities that are served by
these healthcare workers. These findings are shown in Table 4 .
In the EMR, similar studies are rare. In Egypt, among 310 health care
workers at Tanta University Hospital, high levels of stigma and
discrimination against PLHIV were reported15. Only
24.0% had previous contact with PLHIV during work and 21.3% felt
worried to touch cloths of HIV patients; 26.4% were worried to dress
the wounds of patients living with HIV and 27.4% were afraid to get
blood sample from HIV patients. Those unwilling to offer care for PLHIV
represented 40%. Out of the participants, 78.7% reported that HIV
patients should be ashamed of themselves; 48% and 43% preferred not to
provide medical services to MSM and SW suspected to have HIV infection,
respectively. Another report from Kingdom Saudi Arabia in 2014 included
a total number of 90 heath care workers, and showed a lack of knowledge
among this population16. An older paper, from Morocco,
reported that 266 healthcare workers were surveyed in 2002 and they
showed a satisfactory knowledge about HIV but a high level of stigma
toward PLHIV17.
Many factors limit our study. First, no demographic or behavioral
variables (except the place of delivery of the workshop) were collected
which would have given more insight into the possible predictors of
knowledge. A redesign of the questionnaire might be taken into
consideration for the future workshops. Second, the instrument used in
this report is not validated which makes the comparison with other
studies difficult. However, this is the case in the majority of
knowledge studies as validated questionnaires are usually long and
depend on each country’s epidemic, socio-cultural factors, and
programme’s experience.
Third, the urban/rural dichotomy presented in this study is weak. In our
current dynamics, participants are exposed to in-country travel and
importation of modern ideas. However, rural contexts can show resistance
to accept knowledge that threaten their original beliefs regardless of
what they are exposed to. Fourth, not all participants filled both pre
and post-intervention questionnaires, thereby introducing a certain
amount of selection bias.
However, the current study provides insights about knowledge and
attitudes of 144 healthcare workers, peer educators, outreach workers
and volunteers working in HIV testing centers which has not been
reported before in Lebanon. Moreover, since Lebanon’s response to the
epidemic is relatively better than the majority of the EMR countries,
this evaluation of the intervention can serve as a model for the Region
to achieve better commitment to HIV and improve response toward the
global targets.
In the present study, there was some amount of general information and
knowledge with the trained health care workers, but there were some
gaps. An educational activity will try to clear any misconception or
misleading theory about HIV. These activities among health care workers
are crucial to increase HIV knowledge and reduce high-risk behaviors
among key populations.