Preventive dental care, which includes professional

Nigerian Dental Therapy Students Knowledge, Attitude, and Willingness to Care for Patients with HIV Clement Chinedu Azodo, B.D.S., M.S.C., M.P.H., F.M.C.D.S.; Adebola Oluyemisi Ehizele, B.Ch.D., M.P.H., F.W.A.C.S.; Agnes Umoh, R.M., B.D.S., F.M.C.D.S.; Robinson Okechukwu, B.D.S. Abstract: The objective of this study was to assess Nigerian dental therapy students knowledge, attitudes, and willingness to care for patients with HIV. A twenty-six-item questionnaire was used to conduct a cross-sectional study of the dental therapy students of Federal School of Dental Therapy and Technology, Enugu State, Nigeria. The level of knowledge of HIV transmission and prevention among the respondents was high. However, misconceptions about the transmission of HIV through blood donation, mosquito bite, and sharing cups and plates were noted. Erroneous descriptions of HIV as harmless, self-limiting, antibiotic sensitive infection, punishment virus, and contagious infection were also reported. More than half (56.2 percent) and 25.2 percent of the respondents, respectively, expressed feelings of empathy and sympathy towards individuals with HIV. About three-quarters (74.3 percent) expressed willingness to treat patients with HIV, and 87.6 percent expressed confidence in their ability to prevent occupational HIV acquisition. This expressed confidence was significantly associated with their willingness to treat patients with HIV. More than half (55.7 percent) of the respondents reported they can adequately deliver HIV-related information to patients. A total of 86.2 percent said there is a need for training dental therapists in the clinical care of patients with HIV, and 89.0 percent said that dental therapists can play a significant role in the dissemination of HIV-related information. The vast majority (90.0 percent) expressed willingness to disseminate HIV-related information, and the majority (70.5 percent) considered the dental therapist the most suitable dental professional to give HIV-related information to patients. Dr. Azodo is Lecturer, Department of Periodontics, University of Benin, Benin City, Nigeria; Dr. Ehizele is Lecturer, Department of Periodontics, University of Benin, Benin City, Nigeria; Dr. Umoh is Lecturer, Department of Periodontics, University of Benin, Benin City, Nigeria; and Dr. Okechukwu is Dental Officer, Federal School of Dental Therapy and Technology, Nigeria. Direct correspondence and requests for reprints to Dr. Clement Chinedu Azodo, Department of Periodontics, New Dental Complex, University of Benin Teaching Hospital, P.M.B. 1111 Ugbowo, Benin City, Edo State, Nigeria 300001; clementazodo@yahoo.com. Keywords: dental hygiene students, dental therapy students, HIV/AIDS, Nigeria Submitted for publication 3/12/12; accepted 6/19/12 Preventive dental care, which includes professional scaling and polishing, leads to improvement in oral health, overall health, and general well-being of people living with HIV. 1 Scaling and polishing are a certified role of dental therapists who are operative clinical dental auxiliaries. Dental therapy students constitute a risk group for occupational acquisition of HIV infection because of the deficient infection control practices and occupational exposures to blood and body fluids of patients whose HIV status is either known or unknown during their training. Enugu State, where our study was conducted, is one of the five states that make up the Southeast geopolitical zone of Nigeria. It has HIV seroprevalence of 6.5 percent, which is higher than the national seroprevalence average of 4.4 percent. 2 This high prevalence of HIV infections is an indicator of heightened occupational HIV risk in a dental health care setting in the state, especially as HIV-infected patients are seeking dental care in increasing numbers. 3 Amadi et al. 3 reported the prevalence of HIV among dental patients as 4.0 percent in Enugu State, Nigeria. The beliefs and attitudes of dentists and their occupational HIV risk perception have been cited as reasons for the refusal of dentists to render oral health care to individuals with HIV. 4 Incorporation of cultural sensitivity training into all dental and dental hygiene school curricula and mandatory biennial continuing education on HIV/AIDS for dentists and dental hygienists have been recommended as ways to remove barriers to care and increase access to oral health care for people living with HIV/AIDS within community settings. 5 The development of adequate and proper educational interventions that will improve care for people with HIV in Nigeria and eliminate gaps in knowledge among dental therapy students will depend on baseline information. Our study was thus designed to assess dental therapy stu- June 2013 Journal of Dental Education 793

dents HIV-related knowledge, attitude, educational needs, and willingness to care for patients with HIV. The Nigeria 2007 population census and Nigeria health workforce statistics as of December 2007 put the number of doctors and dentists in the Southeast region of the country at 198.8 doctors per million people, signifying that the health workforce in Nigeria is still very deficient. Given the relatively high prevalence of HIV infection, all the members of the health profession are needed for patient education. Although dental therapists are employees in dental practices and are not able to practice independently from dentists in Nigeria, they are very important as participants in health education. Dental therapists are therefore expected to play a significant role in HIV patient education as they deliver oral hygiene instruction after nonsurgical periodontal therapy. In Nigeria, dental therapists play the role that dental hygienists play in other countries. Dental therapy is a full-time modular course and spans forty months for the award of the Higher National Diploma (HND). Dental therapy students take a course in the third year on care of hospital patients. Thus, the literature review and research comparison for our study were done with that of dental hygienists. Published studies on the knowledge and attitudes of dental hygiene students towards patients with HIV are scarce, 6 and the available ones are mostly combined with dental students, which may mask the real facts about dental hygiene students. 7-9 Some retrievable studies on infection control and HIV-related knowledge and attitudes on clinical dental auxiliaries have been conducted among practicing dental hygienists and dental surgery assistants combined and practicing dental hygienists in the United States, The Netherlands, and Italy. 10-18 This review of literature on HIV-related studies showed that although dental therapists/hygienists are one of the key players in the fight against HIV/AIDS, very little research has been done amongst dental therapists and dental therapy students. The objective of our study was thus to assess Nigerian dental therapy students knowledge, misconceptions, attitude, and willingness to care for patients with HIV. Materials and Methods After the necessary permission was obtained from the school s Institutional Review Board, this cross-sectional survey was conducted among the first- through fourth-year dental therapy students of the Federal School of Dental Therapy and Technology, Enugu State, Nigeria. All the dental therapy students of the school were included because of the small size of the study population (335 students) and the lack of baseline data on knowledge, attitude, and willingness to care for people with HIV among this group of dental professionals in Nigeria. The administrative record of the Department of Dental Therapy showed that the lower class had 219 students (Year I=115 students and Year II=104 students) while the higher class had 116 students (Year III=56 students and Year IV=60 students). The data collection tool was a two-page, twenty-six-item, self-administered questionnaire with eight minutes completion time obtained from pretesting among dental students in University of Benin, Benin City, Nigeria. The reliability and stability of the questionnaire were ascertained by the pretesting. The questionnaire assessed the demographics, knowledge of HIV/AIDS, attitude and willingness to treat patients with HIV, confidence on the prevention of occupational HIV acquisition, role in HIV information dissemination, adequacy of clinical training in caring for patients with HIV, and public HIV information dissemination. The first five questions on demographics assessed age, gender, class, marital status, and religion. Eight questions assessed knowledge of the mode of transmission of HIV, while three questions assessed knowledge of the ways of preventing HIV transmission. Six questions assessed perceived confidence in preventing occupational HIV acquisition, their role in HIV-related information dissemination, self-assessed adequacy on clinical training in caring for patients with HIV, and public HIV information dissemination. Four questions assessed the students feelings towards individuals with HIV and willingness to provide care to patients with HIV. Assessment of willingness was done using a question with dichotomous yes/no response. The positive and negative responses to the question were considered to be willingness and unwillingness to treat individuals with HIV, respectively. The questionnaire was hand-delivered and completed during a normal classroom session. Students absent from classes during the period of study were excluded. Recruitment was voluntary, and no incentive was offered. Prior to participation, the aim of the study was explained to the students, and informed consent was obtained. The data were subjected to descriptive statistics in form of frequencies, percentages, cross-tabulation, and nonparametric analyses in the form of chi-square statistics using SPSS Version 794 Journal of Dental Education Volume 77, Number 6

17.0. A p-value of <0.05 was considered significant. For the purpose of analysis, the first- and secondyear students were categorized as those in the lower class, while the third- and fourth-year students were categorized as those in the higher class. Results A total of 290 questionnaires were distributed, with 190 and 100 questionnaires distributed in the lower class and higher class, respectively. This meant that the non-recruitment rate in the lower class was 13.2 percent (29/219), while that in the higher class was 13.8 percent (16/116). Of the 290 questionnaires distributed, 210 questionnaires were returned filled, giving an overall response rate of 72.4 percent. The response rate for students in the lower class was 65.8 percent (125/190), while that for the higher class was 85.0 percent (85/100). The majority of the respondents were in the twenty to twenty-three years of age group, female, single, in the first-year class, and of Catholic religion (Table 1). The level of knowledge of the mode of HIV transmission and its prevention among the respondents was high. However, misconceptions about transmission of HIV existed, with the highest being for blood donation followed by mosquito bite and sharing cups and plates. Knowledge about prevention of HIV was higher among respondents in the lower class. Overall, knowledge of HIV transmission was not significantly different among respondents in the lower and higher classes (Table 2). More than twothirds (68.1 percent) of the respondents correctly Table 1. Demographic characteristics of respondents Characteristic Number Percentage Age (years) <20 37 17.6% 20-23 94 44.8% 24-27 63 30.0% >27 16 7.6% Gender Male 67 31.9% Female 143 68.1% Marital status Single 190 90.5% Married 20 9.5% Class in school Lower 125 59.5% Upper 85 40.5% Religion Catholic 88 41.9% Pentecostal 68 32.4% Anglican 36 17.1% Islam 3 1.4% Traditional 3 1.4% Other 12 5.7% Total 210 100.0% described HIV as a serious and deadly infection, while erroneous descriptions of the infection as harmless, self-limiting, antibiotic sensitive infection, punishment virus, and contagious infection were also reported (Table 3). More than half (56.2 percent) and one-quarter Table 2. General knowledge about HIV transmission and prevention among the respondents Correct Knowledge Incorrect/No Knowledge Lower Class Upper Class Total Lower Class Upper Class Total Characteristic N (%) N (%) N (%) N (%) N (%) N (%) Modes of transmission Sexual 124 (99.2%) 84 (98.8%) 208 (99.0%) 1 (0.8%) 1 (1.2%) 2 (1.0%) Mosquito bite 113 (90.4%) 71 (83.5%) 184 (87.6%) 12 (9.6%) 14 (16.5%) 28 (13.3%) Intravenous needle 116 (92.8%) 85 (100%) 201 (95.7%) 9 (7.2%) 0 (0) 9 (4.3%) Shaking of hands 123 (98.4%) 79 (92.9%) 202 (96.2%) 2 (1.6%) 6 (7.1%) 8 (3.8%) Blood transfusion 119 (95.2%) 81 (95.3%) 200 (95.2%) 6 (4.8%) 4 (4.7%) 10 (4.8%) Blood donation 97 (77.6%) 73 (85.9%) 170 (81.0%) 28 (22.4%) 12 (14.1%) 40 (19.0%) Sharing cups/plates 109 (87.2%) 77 (90.6%) 186 (88.6%) 16 (12.8%) 8 (9.4%) 24 (11.4%) Modes of prevention Abstinence 113 (90.4%) 71 (83.5%) 184 (87.6%) 12 (9.6%) 14 (16.5%) 26 (12.4%) Fidelity 100 (80.0%) 66 (77.6%) 166 (79.0%) 25 (20.0%) 19 (22.4%) 44 (21.0%) Condom 83 (66.4%) 56 (65.9%) 139 (66.2%) 42 (33.6%) 29 (34.1%) 71 (33.8%) June 2013 Journal of Dental Education 795

(25.2 percent) of the respondents, respectively, expressed feeling of empathy and sympathy toward individuals with HIV. However, about a tenth (9.5 percent) of the respondents said they were disgusted by individuals with HIV. Respondents in the lower class expressed empathy more than those in the higher class (Table 4). About three-quarters (74.3 percent) expressed willingness to treat patients with HIV, and this willingness was higher among respondents in the lower class than those in the higher class (Table 5). The willingness to treat patients with HIV was not significantly associated with age, gender, religion, marital status, or knowing people with HIV. The majority (87.6 percent) expressed confidence in their ability to protect themselves from becoming infected with HIV in the professional setting, and this was higher among respondents in the lower class than those in the higher class (Table 6). This expressed confidence in preventing occupational exposure was significantly associated with expressed willingness to treat patients with HIV (Table 7). Self-assessed adequacy in HIV-related information delivery was reported among 55.7 percent of the respondents. A total of 86.2 percent and 89.0 percent, respectively, expressed need for training in the clinical care of patients with HIV and considered Table 3. Respondents descriptions of HIV Opinion N (%) N (%) N (%) p-value Serious and deadly infection 80 (64.0%) 63 (74.1%) 143(68.1%) 0.08 Not sure 13 (10.4%) 12 (14.1%) 25 (11.9%) Self-limitation 13 (10.4%) 5 (5.9%) 18 (8.6%) Antibiotics-responsive infection 6 (4.8%) 2 (2.4%) 8 (3.8%) Harmless infection 7 (5.6%) 0 (0) 7 (3.3%) Preventable infection 1 (0.8%) 1(1.2%) 2 (1.0%) Contagious infection 2 (1.6%) 0 (0) 2 (1.0%) Punishment virus 2 (1.6%) 0 (0) 2 (1.0%) Illness that can be managed 0 (0) 1 (1.2%) 1 (0.5%) Stigmatizing infection 0 (0) 1 (1.2%) 1 (0.5%) Viral infection transmitted by sex and unsterilized instruments 1 (0.8%) 0 (0) 1 (0.5%) Table 4. Respondents reported feelings towards individuals with HIV Feeling N (%) N (%) N (%) p-value Empathy 75 (60.0%) 43 (50.6%) 118 (56.2%) 0.19 Sympathy 25 (20.0%) 28 (32.9%) 53 (25.2%) Disgust 13 (10.4%) 7 (8.2%) 20 (9.5%) Indifferent 6 (4.8%) 5 (5.9%) 11 (5.2%) Anger 4 (3.2%) 0 (0) 4 (1.9%) Normal 2 (1.6%) 2 (2.4%) 4 (1.9%) Table 5. Respondents reported willingness to treat patients with HIV Willingness N (%) N (%) N (%) p-value Agree 97 (77.6%) 59 (69.4%) 156 (74.3%) 0.36 Undecided 19 (15.2%) 16 (18.8%) 35 (16.7%) Disagree 9 (7.2%) 10 (11.8%) 19 (9.0%) 796 Journal of Dental Education Volume 77, Number 6

Table 6. Respondents reported confidence in preventing self from occupational HIV exposure Confidence N (%) N (%) N (%) p-value Yes 114 (91.2%) 70 (82.4%) 184 (87.6%) 0.16 No 7 (5.6%) 9 (10.6%) 16 (7.6%) Not sure 4 (3.2%) 6 (7.1) % 10 (4.8%) Table 7. Relationship between respondents perceived confidence in preventing self from occupational HIV exposure and willingness to treat patients with HIV Confidence Yes No Unsure Total Willingness N (%) N (%) N (%) N (%) p-value Agree 142 (77.2%) 8 (50.0%) 6 (60.0%) 156 (74.3%) 0.03 Undecided 25 (13.6%) 6 (37.5%) 4 (40.0%) 35 (16.7%) Disagree 17 (9.2%) 2 (12.5%) 0 (0) 19 (9.0%) Total 184 (100%) 16 (100%) 10 (100%) 210 (100%) the dental therapist as having roles in the dissemination of HIV-related information. The majority (90.0 percent) expressed willingness to disseminate HIVrelated information; this percentage was higher among respondents in the lower than the higher class (Table 8). Seventy percent of the respondents considered the dental therapist the most suitable dental professional to give HIV-related information to patients, followed by the dentist and the dental surgery assistant (Table 9). Discussion Overall, the respondents in this study revealed high levels of correct knowledge of the modes of HIV transmission and prevention. However, there were some gaps in knowledge as 19.0 percent, 13.3 percent, and 11.4 percent of the respondents, respectively, erroneously stated that HIV can be contracted through blood donation, mosquito bite, and sharing of cups and plates with individuals with HIV. A survey among dental hygiene students two decades ago also found incomplete knowledge and some confusion about knowledge of transmission of HIV. 19 The level of deficiency and incomplete knowledge about mode of HIV transmission findings in our study was lower than the reported findings among dental nursing students in Nigeria 20 and Sudanese dental students in Khartoum. 21 This reflects a decrease in misconceptions about the mode of transmission of HIV among dental professionals, which may be due to increasing availability of sources of information on general HIV knowledge and receptive learning interest on HIV-related issues. 9,22 More than two-thirds (68.1 percent) of the respondents correctly described HIV as a serious and deadly infection. This may be because the morbidity and mortality of the infection in Nigeria and worldwide are now very obvious. The erroneous description of the infection as harmless, self-limiting, antibiotic sensitive infection, punishment virus, and contagious infection was also reported among the respondents. This may be explained by the low self-assessed adequacy (55.7 percent) in HIV-related information delivery among of the respondents in our study. A dental clinic is a health-promoting workplace and a site where preventive strategies such as voluntary counseling and testing can be explored. The choice of dental therapists among the respondents as the most suitable dental professional to give HIVrelated information to patients in the dental clinic setting is a confirmation of the role of dental therapists as primary prevention specialists. The choice of dental therapists may also be responsible for the expressed June 2013 Journal of Dental Education 797

Table 8. Respondents training needs, self-assessed adequacy in HIV-related information, and willingness to disseminate HIV-related information Characteristic N (%) N (%) N (%) p-value Self-assessed adequacy in HIV-related information delivery 0.50 Yes 71 (56.8%) 46 (54.1%) 117 (55.7%) No 39 (31.2%) 32 (37.6%) 71 (33.8%) Don t know 15 (12.0%) 7 (8.2%) 22 (10.5%) Expressed training needs 0.17 Yes 108 (86.4%) 73 (85.9%) 181 (86.2%) No 10 (8.0%) 11 (12.9%) 21 (10.0%) Don t know 7 (5.6%) 1 (1.2%) 8 (3.8%) Perceived role of dental therapist in HIV-related information 0.16 dissemination Yes 108 (86.4%) 79 (92.9%) 187 (89.0%) No 9 (7.2%) 3 (3.5%) 12 (5.7%) Don t know 8 (6.4%) 3 (3.5%) 11 (5.2%) Expressed willingness to disseminate HIV-related information 0.46 Yes 115 (92.0%) 74 (87.1%) 189 (90.0%) No 4 (3.2%) 5 (5.9%) 9 (4.3%) Don t know 6 (4.8%) 6 (7.1%) 12 (5.7%) Table 9. Respondents opinion of most suitable dental professional to give HIV-related information to patients Dental Professional N (%) N (%) N (%) p-value Dental therapist 87 (69.6%) 61 (71.8%) 148 (70.5%) 0.67 Dentist 16 (12.8%) 14 (16.5%) 30 (14.3%) Dental surgery assistant 16 (12.8%) 7 (8.2%) 23 (11.0%) Dental record officer 4 (3.2%) 3 (3.5%) 7 (3.3%) Dental technologist 2 (1.6%) 0 (0) 2 (1.0%) willingness among respondents in our study to disseminate HIV-related information to patients and the general public. Such education can be hindered by the considerable gap in knowledge on mode of HIV prevention among the respondents, which justifies the need for curriculum modification focusing on detailed information on mode of transmission and prevention of HIV transmission. Such training will equip dental therapy students to achieve their roles in oral health care for people with HIV. In this study, the dental therapy students willingness to treat patients with HIV was high. It is higher than the findings of previous research among dental professionals 23 and dental students 24 in Nigeria. This could be explained by the high level of confidence expressed by the respondents in protecting against occupational HIV transmission. Other studies have found that dental hygienists who were not worried about acquiring HIV in the workplace 5 and dental students with confidence in safely treating patients with HIV are more willing to treat patients with HIV. 25 The high level of knowledge of HIV/AIDS noted in our study may be contributory, as previous studies have linked knowledge of HIV-related issues with willingness to treat patients with HIV. 4,9 Minimal bias toward individuals with AIDS was reported among dental hygiene students in Maryland. 18 South African oral hygiene and dental students expressed the opinion that the same dignity and respect given to patients with other illnesses 798 Journal of Dental Education Volume 77, Number 6

should be given to patients with HIV. 7 The willingness to treat patients with HIV was higher among respondents in the lower class than those in the higher class. This can be explained by higher general knowledge, empathy towards individuals with HIV, and expressed confidence in protecting oneself from occupational HIV exposure. Further improvement in willingness is desirable through educational interventional programs as these have been found to improve knowledge, attitudes, and willingness to care for patients with HIV among health professionals. 26,27 In our study, the respondents feelings towards individuals with HIV were predominantly empathy followed by sympathy. Although empathy is the advocated feeling of health workers towards their patients, 28 the sympathetic feeling found in our study was also encouraging and more favorable than the discriminatory and antagonistic feelings previously reported among dental professionals and health workers in Nigeria. 29,30 The inclusion of additional information on HIV in the School of Dental Therapy curriculum would help eliminate gaps in knowledge, improve the students attitude, and increase their willingness and competence in treating individuals with HIV as a majority of the respondents expressed the need for clinical training on HIV care. A previous study also reported the interest of dental hygiene students in learning more about treating patients with HIV/AIDS. 9 Conclusion The level of knowledge of HIV transmission and prevention among dental therapist students in our study was high, but misconceptions that need clarification and further education still exist. The students willingness to treat patients with HIV was high although further improvement is desirable through sustained training and interventional behavioral change. REFERENCES 1. Brown JB, Rosenstein D, Mullooly J, Rosetti MO, Robinson S, Chiodo G. Impact of intensified dental care on outcomes in human immunodeficiency virus infection. AIDS Patient Care STDS 2002;16(10):479-86. 2. Federal Ministry of Health. 2005 national HIV seroprevalence sentinel survey process and findings. Abuja, Nigeria: National AIDS/STDs Control Program, 2006. 3. Amadi ES, Ononiwu C, Aballa N, Oladimeji SA, Aneke F, Aneke C, Azeez O. Seroprevalence of human immunodeficiency virus among patients attending Federal Dental Clinic, Enugu, Nigeria. Internet J Dent Sci 2009;7(2). 4. McCarthy GM, Koval JJ, MacDonald JK. Factors associated with refusal to treat HIV-infected patients: the results of a national survey of dentists in Canada. Am J Public Health 1999;89(4):541-5. 5. Clark-Alexander B. 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edge and attitudes of Japanese dental health care workers towards HIV-related disease. J Dent 1997;25(3-4):279-83. 23. Adedigba MA, Ogunbodede EO, Fajewonyomi BA, Ojo OO, Naidoo S. Gender differences among oral health care workers in caring for HIV/AIDS patients in Osun State, Nigeria. Afr Health Sci 2005;5(3):182-7. 24. Azodo CC, Ehigiator O, Oboro HO, Ehizele AO, Umoh A, Ezeja EB, et al. Nigerian dental students willingness to treat HIV-positive patients. J Dent Educ 2010;74(4): 446-52. 25. Hu SW, Lai HR, Liao PH. Comparing dental students knowledge of and attitudes toward hepatitis B virus, hepatitis C virus-, and HIV-infected patients in Taiwan. AIDS Patient Care STDS 2004;18(10):587-93. 26. Mockiene V, Suominen T, Välimäki M, Razbadauskas A. Impact of intervention programs on nurses knowledge, attitudes, and willingness to take care of patients with human immunodeficiency virus/acquired immunodefi- ciency syndrome: a descriptive review. Medicina (Kaunas) 2010;46(3):159-68. 27. Mockiene V, Suominen T, Valimaki M, Razbadauskas A, Martinkenas A, Caplinskas S. The impact of an education intervention to change nurses HIV-related knowledge and attitudes in Lithuania: a randomized controlled trial. J Assoc Nurses AIDS Care 2011;22(2):140-9. 28. Sherman J, Cramer A. Measurement of changes in empathy during dental school. J Dent Educ 2005;69(3):338-45. 29. Bukar A, Gofwen R, Adeleke OA, Taiwo OO, Danfillo IS, Jalo PH. Discriminatory attitudes towards patients with HIV/AIDS by dental professionals in Nigeria. Odontostomatol Trop 2008;31(122):34-40. 30. Aisien AO, Shobowale MO. Health care workers knowledge on HIV and AIDS: universal precautions and attitude towards PLWHA in Benin-City, Nigeria. Niger J Clin Pract 2005;8(2):74-82. 800 Journal of Dental Education Volume 77, Number 6