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.