Willingness to care for blood-borne virus-infected patients in Thailand

Willingness to care for blood-borne virus-infected patients in Thailand Abstract Background Although stigma and discrimination by nurses against patients infected with human immunodeficiency virus (HIV) or hepatitis C virus (HCV) have been reported, potential determinants of nurses’ willingness to care for these patients have not been well studied in Thailand. Aims To identify factors associated with Thai nurses’ willingness to care for patients infected with HIV or HCV. Methods Multivariable logistic regression analysis of data from a questionnaire completed by nurses at a large hospital in Bangkok, Thailand. Results Of 626 nurses, 546 (87%) nurses participated. Eleven per cent (59) and 6% (34) had previously experienced HIV- or HCV-infected blood contamination incidents, respectively. Forty-four per cent (240) and 38% (208) reported unwillingness to care for HIV- or HCV-infected patients, respectively. Willingness to care was less common [adjusted odds ratios 0.51 (0.34–0.74) for HIV and 0.62 (0.42–0.89) for HCV] in nurses aged ≥ 40 years and in those who feared HCV [0.63 (0.37–0.99)], but not HIV [0.84 (0.5–1.26)] transmission. Nurses who had confidence in protecting themselves against infection with HIV [1.84 (1.52–2.04)] and HCV [1.87 (1.45–2.18)], and accepting attitudes towards HIV-infected co-workers [1.39 (1.08–1.66)] but not HCV-infected co-workers [1.16 (0.83–1.5)], were more willing to care for HIV- and HCV-infected patients. Conclusions Around 4 in 10 Thai nurses in our sample were unwilling to care for HIV- or HCV-infected patients. Minimizing the risk of nosocomial transmission and improving the public perception of infected individuals may help improve nurses’ willingness to care for such patients, in Thailand or elsewhere. Attitude, hepatitis C virus, human immunodeficiency virus, nurses Introduction Healthcare is one of the main areas in which people infected with blood-borne viruses experience discrimination [1]. Hepatitis B infection is preventable, but there is no vaccine against the human immunodeficiency virus (HIV) or hepatitis C virus (HCV). Discrimination by healthcare workers against HIV- or HCV-infected patients can include denial of care, breaches of confidentiality, inappropriate and unethical behaviour and excessive use of precautions [2–5]. In Thailand, in 2013, estimated adult prevalence rates were 1.1% for HIV and 2.7% for HCV [6,7]. Perceived stigma and discrimination against infected patients by healthcare workers have been reported in developed and developing countries [8,9]. However, the literature is scarce regarding potential determinants of willingness to care for these patients in Thailand. This study aimed therefore to identify factors associated with Thai nurses’ willingness to care for HIV- or HCV-infected patients. Methods We used a descriptive, cross-sectional design in our study of nurses at a 1200-bed hospital in Bangkok, one of the largest hospitals in Thailand. The target population was 626 nurses providing direct patient care at the hospital. We excluded male participants because of their small proportion of the overall sample. We adapted a questionnaire from similar investigations undertaken in Japan and Vietnam [4,5,10–12]. We translated the original questionnaire into Thai, using standard translation and back translation [13,14]. The questionnaire had been validated in a series of studies [4,5,10–12] and slightly modified for a Thai context, following consultation with a panel of local healthcare experts. In June 2016, researchers distributed the questionnaire, an information sheet describing the background and study protocol, a consent form and general goods worth about two US dollars as a reward to potential participants through the head nurses in 13 nursing units. Participants completed the questionnaire and consent form, which they placed in a return box, in a sealed envelope, at each nursing unit. Researchers collected the contents of the return boxes for 2 weeks following initial distribution. Ethical approval was granted by the Ethical Review Committee for Human Research, Mahidol University and the Institutional Review Board committee of the hospital. Demographic data collected included age, marital status, hospital ward, work years, training in universal precautions in the preceding 12 months and wearing gloves during all patient care activities (Table 1). Three questions asked whether the participant had cared for an HIV- or HCV-infected patient in the past 12 months, ever personally experienced a needle-stick or other sharps injury while dealing with a patient, or ever personally experienced HIV or HCV testing. Six questions addressed attitudes towards HIV- and HCV-infected patients or colleagues (Table 2). Response options were agree, somewhat agree, somewhat disagree and disagree. Questions about HIV and HCV were asked in a separate section of the questionnaire. Table 1. Demographics of participants (n = 546) n (%) Age  20–29 years 241 (44)  30–39 years 151 (28)  40 years and older 154 (28) Marital status  Married 169 (31)  Single 356 (65)  Divorced/widowed 21 (4) Hospital wards  Internal medicine 130 (24)  Surgery/emergency 131 (24)  Obstetrics/paediatrics 105 (19)  Others 180 (33) Work years  0–9 years 265 (52)  10–19 years 128 (23)  20 years or more 153 (25) Cared for a patient infected with HIV or HCV in the last 12 months  HIV (yes) 342 (63)  HCV (yes) 245 (45) Experienced a needle-stick or sharps injury (ever) from a patient infected with HIV or HCV  HIV (yes) 59 (11)  HCV (yes) 34 (6) Experienced HIV or HCV testing (ever)  HIV (yes) 428 (78)  HCV (yes) 262 (48) Received training related to universal precaution in the last 12 months  Yes 394 (72) Wore gloves during all patient care activities  Yes 267 (49) n (%) Age  20–29 years 241 (44)  30–39 years 151 (28)  40 years and older 154 (28) Marital status  Married 169 (31)  Single 356 (65)  Divorced/widowed 21 (4) Hospital wards  Internal medicine 130 (24)  Surgery/emergency 131 (24)  Obstetrics/paediatrics 105 (19)  Others 180 (33) Work years  0–9 years 265 (52)  10–19 years 128 (23)  20 years or more 153 (25) Cared for a patient infected with HIV or HCV in the last 12 months  HIV (yes) 342 (63)  HCV (yes) 245 (45) Experienced a needle-stick or sharps injury (ever) from a patient infected with HIV or HCV  HIV (yes) 59 (11)  HCV (yes) 34 (6) Experienced HIV or HCV testing (ever)  HIV (yes) 428 (78)  HCV (yes) 262 (48) Received training related to universal precaution in the last 12 months  Yes 394 (72) Wore gloves during all patient care activities  Yes 267 (49) View Large Table 1. Demographics of participants (n = 546) n (%) Age  20–29 years 241 (44)  30–39 years 151 (28)  40 years and older 154 (28) Marital status  Married 169 (31)  Single 356 (65)  Divorced/widowed 21 (4) Hospital wards  Internal medicine 130 (24)  Surgery/emergency 131 (24)  Obstetrics/paediatrics 105 (19)  Others 180 (33) Work years  0–9 years 265 (52)  10–19 years 128 (23)  20 years or more 153 (25) Cared for a patient infected with HIV or HCV in the last 12 months  HIV (yes) 342 (63)  HCV (yes) 245 (45) Experienced a needle-stick or sharps injury (ever) from a patient infected with HIV or HCV  HIV (yes) 59 (11)  HCV (yes) 34 (6) Experienced HIV or HCV testing (ever)  HIV (yes) 428 (78)  HCV (yes) 262 (48) Received training related to universal precaution in the last 12 months  Yes 394 (72) Wore gloves during all patient care activities  Yes 267 (49) n (%) Age  20–29 years 241 (44)  30–39 years 151 (28)  40 years and older 154 (28) Marital status  Married 169 (31)  Single 356 (65)  Divorced/widowed 21 (4) Hospital wards  Internal medicine 130 (24)  Surgery/emergency 131 (24)  Obstetrics/paediatrics 105 (19)  Others 180 (33) Work years  0–9 years 265 (52)  10–19 years 128 (23)  20 years or more 153 (25) Cared for a patient infected with HIV or HCV in the last 12 months  HIV (yes) 342 (63)  HCV (yes) 245 (45) Experienced a needle-stick or sharps injury (ever) from a patient infected with HIV or HCV  HIV (yes) 59 (11)  HCV (yes) 34 (6) Experienced HIV or HCV testing (ever)  HIV (yes) 428 (78)  HCV (yes) 262 (48) Received training related to universal precaution in the last 12 months  Yes 394 (72) Wore gloves during all patient care activities  Yes 267 (49) View Large Table 2 Attitudes towards HIV- and HCV-infected patients (n = 546) HIV, n (%) HCV, n (%) I fear transmission from patients infected with HIV or HCV.  Agree 61 (11) 77 (14)  Somewhat agree 195 (36) 178 (33)  Somewhat disagree 166 (30) 165 (30)  Disagree 124 (23) 126 (23) I am confident that I can protect myself against infection when caring for a patient infected with HIV or HCV.  Agree 238 (44) 251 (46)  Somewhat agree 256 (47) 246 (45)  Somewhat disagree 40 (7) 31 (6)  Disagree 12 (2) 18 (3) I avoid going near people infected with HIV or HCV.  Agree 35 (6) 18 (3)  Somewhat agree 114 (21) 81 (15)  Somewhat disagree 202 (37) 196 (36)  Disagree 196 (36) 251 (46) I link people infected with HIV or HCV to homosexuality, injectable drug use or having multiple sex partners.  Agree 67 (12) 40 (7)  Somewhat agree 232 (43) 128 (24)  Somewhat disagree 149 (27) 182 (33)  Disagree 98 (18) 196 (36) I think nurses infected with HIV or HCV can continue nursing care if their viral level is low or without high-risk procedures.  Agree 142 (26) 130 (24)  Somewhat agree 256 (47) 259 (47)  Somewhat disagree 107 (20) 112 (21)  Disagree 41 (7) 45 (8) I am willing to care for a patient who is infected with HIV or HCV.  Agree 76 (14) 93 (17)  Somewhat agree 230 (42) 245 (45)  Somewhat disagree 176 (32) 159 (29)  Disagree 64 (12) 49 (9) HIV, n (%) HCV, n (%) I fear transmission from patients infected with HIV or HCV.  Agree 61 (11) 77 (14)  Somewhat agree 195 (36) 178 (33)  Somewhat disagree 166 (30) 165 (30)  Disagree 124 (23) 126 (23) I am confident that I can protect myself against infection when caring for a patient infected with HIV or HCV.  Agree 238 (44) 251 (46)  Somewhat agree 256 (47) 246 (45)  Somewhat disagree 40 (7) 31 (6)  Disagree 12 (2) 18 (3) I avoid going near people infected with HIV or HCV.  Agree 35 (6) 18 (3)  Somewhat agree 114 (21) 81 (15)  Somewhat disagree 202 (37) 196 (36)  Disagree 196 (36) 251 (46) I link people infected with HIV or HCV to homosexuality, injectable drug use or having multiple sex partners.  Agree 67 (12) 40 (7)  Somewhat agree 232 (43) 128 (24)  Somewhat disagree 149 (27) 182 (33)  Disagree 98 (18) 196 (36) I think nurses infected with HIV or HCV can continue nursing care if their viral level is low or without high-risk procedures.  Agree 142 (26) 130 (24)  Somewhat agree 256 (47) 259 (47)  Somewhat disagree 107 (20) 112 (21)  Disagree 41 (7) 45 (8) I am willing to care for a patient who is infected with HIV or HCV.  Agree 76 (14) 93 (17)  Somewhat agree 230 (42) 245 (45)  Somewhat disagree 176 (32) 159 (29)  Disagree 64 (12) 49 (9) View Large Table 2 Attitudes towards HIV- and HCV-infected patients (n = 546) HIV, n (%) HCV, n (%) I fear transmission from patients infected with HIV or HCV.  Agree 61 (11) 77 (14)  Somewhat agree 195 (36) 178 (33)  Somewhat disagree 166 (30) 165 (30)  Disagree 124 (23) 126 (23) I am confident that I can protect myself against infection when caring for a patient infected with HIV or HCV.  Agree 238 (44) 251 (46)  Somewhat agree 256 (47) 246 (45)  Somewhat disagree 40 (7) 31 (6)  Disagree 12 (2) 18 (3) I avoid going near people infected with HIV or HCV.  Agree 35 (6) 18 (3)  Somewhat agree 114 (21) 81 (15)  Somewhat disagree 202 (37) 196 (36)  Disagree 196 (36) 251 (46) I link people infected with HIV or HCV to homosexuality, injectable drug use or having multiple sex partners.  Agree 67 (12) 40 (7)  Somewhat agree 232 (43) 128 (24)  Somewhat disagree 149 (27) 182 (33)  Disagree 98 (18) 196 (36) I think nurses infected with HIV or HCV can continue nursing care if their viral level is low or without high-risk procedures.  Agree 142 (26) 130 (24)  Somewhat agree 256 (47) 259 (47)  Somewhat disagree 107 (20) 112 (21)  Disagree 41 (7) 45 (8) I am willing to care for a patient who is infected with HIV or HCV.  Agree 76 (14) 93 (17)  Somewhat agree 230 (42) 245 (45)  Somewhat disagree 176 (32) 159 (29)  Disagree 64 (12) 49 (9) HIV, n (%) HCV, n (%) I fear transmission from patients infected with HIV or HCV.  Agree 61 (11) 77 (14)  Somewhat agree 195 (36) 178 (33)  Somewhat disagree 166 (30) 165 (30)  Disagree 124 (23) 126 (23) I am confident that I can protect myself against infection when caring for a patient infected with HIV or HCV.  Agree 238 (44) 251 (46)  Somewhat agree 256 (47) 246 (45)  Somewhat disagree 40 (7) 31 (6)  Disagree 12 (2) 18 (3) I avoid going near people infected with HIV or HCV.  Agree 35 (6) 18 (3)  Somewhat agree 114 (21) 81 (15)  Somewhat disagree 202 (37) 196 (36)  Disagree 196 (36) 251 (46) I link people infected with HIV or HCV to homosexuality, injectable drug use or having multiple sex partners.  Agree 67 (12) 40 (7)  Somewhat agree 232 (43) 128 (24)  Somewhat disagree 149 (27) 182 (33)  Disagree 98 (18) 196 (36) I think nurses infected with HIV or HCV can continue nursing care if their viral level is low or without high-risk procedures.  Agree 142 (26) 130 (24)  Somewhat agree 256 (47) 259 (47)  Somewhat disagree 107 (20) 112 (21)  Disagree 41 (7) 45 (8) I am willing to care for a patient who is infected with HIV or HCV.  Agree 76 (14) 93 (17)  Somewhat agree 230 (42) 245 (45)  Somewhat disagree 176 (32) 159 (29)  Disagree 64 (12) 49 (9) View Large We conducted univariate statistical analysis to estimate odds ratios and 95% confidence intervals for all variables, to identify factors associated with willingness to care for HIV- or HCV-infected patients. We subsequently undertook multivariable logistic regression using Zhang’s formula to adjust for age, hospital ward, training, wearing gloves, patient care, needle-stick or other sharps injury, and testing, given the common prevalence of these variables [15]. We excluded marital status and work years from the multivariate analysis because of their moderate correlation with age. For the statistical analysis, we categorized responses about attitudes into three groups (1 = agree, 2 = somewhat agree and 3 = disagree/somewhat disagree), and two groups for outcomes (1 = agree/somewhat agree and 2 = disagree/somewhat disagree). We used SPSS Statistics for Windows, Version 17.0 (SPSS Inc., Chicago, IL, USA) for the analyses. We used two-sided statistical tests and considered probability (P) values < 0.05 statistically significant. Results Five hundred and forty-six (546/626) nurses returned valid, completed questionnaires (response rate: 87%), 2% (14) did not participate, 10% (60) returned uncompleted questionnaires and 1% (6) were male. Demographic data for participants, their experience of caring for HIV- or HCV-infected patients and their experience of HIV or HCV exposure incidents are shown in Table 1. Participants’ attitudes towards HIV- and HCV-infected patients and colleagues, and their confidence in protecting themselves against infection are shown in Table 2. Tables 3 and 4 indicate factors associated with willingness to care for HIV- and HCV-infected patients, respectively. Negative determinants of willingness to care were as follows: age ≥ 40, wards other than internal medicine, those who feared HCV, avoiding HIV-infected patients and associating HIV infection with homosexuality, injectable drug use or having multiple sex partners. Willingness to care was positively associated with confidence in protection against infection when caring for infected patients. Accepting attitudes towards infected co-workers having contact with patients was associated with willingness to care for HIV-infected patients but not HCV-infected patients. Nurses who had confidence in protecting themselves against infection with HIV and HCV, and accepting attitudes towards HIV-infected co-workers but not HCV-infected co-workers, were more willing to care for HIV- and HCV-infected patients. Table 3. Factors associated with willingness to care for HIV-infected patients Univariate OR (95% CI) P Adjusted OR (95% CI) P Age  20–29 years 1.00 — — 1.00 — —  30–39 years 0.69 (0.51–0.91) <0.01 0.70 (0.49–0.94) <0.5  40 years and older 0.61 (0.45–0.81) <0.001 0.51 (0.34–0.74) <0.001 Marital statusa  Married 1.00 — —  Single 1.44 (1.24–1.63) <0.001  Divorced/widowed 0.76 (0.37–1.29) Hospital wards  Internal medicine 1.00 — — 1.00 — —  Surgery/emergency 0.81 (0.57–1.09) 0.84 (0.57–1.15)  Obstetrics/paediatrics 0.66 (0.48–0.88) <0.01 1.00 (0.68–1.35)  Others 0.65 (0.47–0.86) <0.01 0.61 (0.41–0.87) <0.01 Work yearsa  0–9 years 1.00 — —  10–19 years 0.64 (0.46–0.85) <0.001  20 years or more 0.66 (0.48–0.87) <0.01 Cared for a patient infected with HIV in the last 12 months  No 1.00 — — 1.00 — —  Yes 1.17 (0.97–1.36) 1.11 (0.87–1.34) Experienced a needle-stick or sharps injury (ever) from a patient infected with HIV  No 1.00 — — 1.00 — —  Yes 0.79 (0.54–1.09) 0.79 (0.51–1.13) Experienced HIV or HCV testing (ever)  No 1.00 — — 1.00 — —  Yes 0.79 (0.59–1.01) 0.78 (0.55–1.05) Received training related to universal precautions in the last 12 months  No 1.00 — — 1.00 — —  Yes 1.05 (0.84–1.26) 0.99 (0.75–1.23) Wore gloves during all patient care activities  No 1.00 — — 1.00 — —  Yes 1.11 (0.92–1.30) 1.04 (0.83–1.26) I fear transmission from patients infected with HIV  Disagree/somewhat disagree 1.00 — — 1.00 — —  Somewhat agree 0.77 (0.60–0.97) <0.05 0.94 (0.70–1.21)  Agree 0.57 (0.36–0.84) <0.01 0.84 (0.50–1.26) I am confident that I can protect against infection while caring for a patient infected with HIV  Disagree/somewhat disagree 1.00 — — 1.00 — —  Somewhat agree 1.44 (1.09–1.74) <0.05 1.46 (1.06–1.78) <0.05  Agree 1.80 (1.52–2.00) <0.001 1.84 (1.52–2.04) <0.001 I avoid going near people infected with HIV  Disagree/somewhat disagree 1.00 — — 1.00 — —  Somewhat agree 0.49 (0.35–0.68) <0.001 0.52 (0.34–0.76) <0.001  Agree 0.44 (0.23–0.75) <0.001 0.50 (0.23–0.95) <0.05 I link people infected with HIV to homosexuality, injectable drug use or having multiple sex partners  Disagree/somewhat disagree 1.00 — — 1.00 — —  Somewhat agree 0.77 (0.60–0.97) <0.05 0.87 (0.65–1.11)  Agree 0.60 (0.39–0.87) <0.01 0.48 (0.28–0.78) <0.001 I think nurses infected with HIV can continue nursing care if their viral level is low or without high-risk procedures  Disagree/somewhat disagree 1.00 — — 1.00 — —  Somewhat agree 1.41 (1.18–1.62) <0.001 1.52 (1.26–1.75) <0.001  Agree 1.44 (1.18–1.67) <0.001 1.39 (1.08–1.66) <0.05 Univariate OR (95% CI) P Adjusted OR (95% CI) P Age  20–29 years 1.00 — — 1.00 — —  30–39 years 0.69 (0.51–0.91) <0.01 0.70 (0.49–0.94) <0.5  40 years and older 0.61 (0.45–0.81) <0.001 0.51 (0.34–0.74) <0.001 Marital statusa  Married 1.00 — —  Single 1.44 (1.24–1.63) <0.001  Divorced/widowed 0.76 (0.37–1.29) Hospital wards  Internal medicine 1.00 — — 1.00 — —  Surgery/emergency 0.81 (0.57–1.09) 0.84 (0.57–1.15)  Obstetrics/paediatrics 0.66 (0.48–0.88) <0.01 1.00 (0.68–1.35)  Others 0.65 (0.47–0.86) <0.01 0.61 (0.41–0.87) <0.01 Work yearsa  0–9 years 1.00 — —  10–19 years 0.64 (0.46–0.85) <0.001  20 years or more 0.66 (0.48–0.87) <0.01 Cared for a patient infected with HIV in the last 12 months  No 1.00 — — 1.00 — —  Yes 1.17 (0.97–1.36) 1.11 (0.87–1.34) Experienced a needle-stick or sharps injury (ever) from a patient infected with HIV  No 1.00 — — 1.00 — —  Yes 0.79 (0.54–1.09) 0.79 (0.51–1.13) Experienced HIV or HCV testing (ever)  No 1.00 — — 1.00 — —  Yes 0.79 (0.59–1.01) 0.78 (0.55–1.05) Received training related to universal precautions in the last 12 months  No 1.00 — — 1.00 — —  Yes 1.05 (0.84–1.26) 0.99 (0.75–1.23) Wore gloves during all patient care activities  No 1.00 — — 1.00 — —  Yes 1.11 (0.92–1.30) 1.04 (0.83–1.26) I fear transmission from patients infected with HIV  Disagree/somewhat disagree 1.00 — — 1.00 — —  Somewhat agree 0.77 (0.60–0.97) <0.05 0.94 (0.70–1.21)  Agree 0.57 (0.36–0.84) <0.01 0.84 (0.50–1.26) I am confident that I can protect against infection while caring for a patient infected with HIV  Disagree/somewhat disagree 1.00 — — 1.00 — —  Somewhat agree 1.44 (1.09–1.74) <0.05 1.46 (1.06–1.78) <0.05  Agree 1.80 (1.52–2.00) <0.001 1.84 (1.52–2.04) <0.001 I avoid going near people infected with HIV  Disagree/somewhat disagree 1.00 — — 1.00 — —  Somewhat agree 0.49 (0.35–0.68) <0.001 0.52 (0.34–0.76) <0.001  Agree 0.44 (0.23–0.75) <0.001 0.50 (0.23–0.95) <0.05 I link people infected with HIV to homosexuality, injectable drug use or having multiple sex partners  Disagree/somewhat disagree 1.00 — — 1.00 — —  Somewhat agree 0.77 (0.60–0.97) <0.05 0.87 (0.65–1.11)  Agree 0.60 (0.39–0.87) <0.01 0.48 (0.28–0.78) <0.001 I think nurses infected with HIV can continue nursing care if their viral level is low or without high-risk procedures  Disagree/somewhat disagree 1.00 — — 1.00 — —  Somewhat agree 1.41 (1.18–1.62) <0.001 1.52 (1.26–1.75) <0.001  Agree 1.44 (1.18–1.67) <0.001 1.39 (1.08–1.66) <0.05 CI, confidence interval; OR, odds ratio. aMarital status and work years were excluded from the multivariate analysis, because of moderate correlation with age. View Large Table 3. Factors associated with willingness to care for HIV-infected patients Univariate OR (95% CI) P Adjusted OR (95% CI) P Age  20–29 years 1.00 — — 1.00 — —  30–39 years 0.69 (0.51–0.91) <0.01 0.70 (0.49–0.94) <0.5  40 years and older 0.61 (0.45–0.81) <0.001 0.51 (0.34–0.74) <0.001 Marital statusa  Married 1.00 — —  Single 1.44 (1.24–1.63) <0.001  Divorced/widowed 0.76 (0.37–1.29) Hospital wards  Internal medicine 1.00 — — 1.00 — —  Surgery/emergency 0.81 (0.57–1.09) 0.84 (0.57–1.15)  Obstetrics/paediatrics 0.66 (0.48–0.88) <0.01 1.00 (0.68–1.35)  Others 0.65 (0.47–0.86) <0.01 0.61 (0.41–0.87) <0.01 Work yearsa  0–9 years 1.00 — —  10–19 years 0.64 (0.46–0.85) <0.001  20 years or more 0.66 (0.48–0.87) <0.01 Cared for a patient infected with HIV in the last 12 months  No 1.00 — — 1.00 — —  Yes 1.17 (0.97–1.36) 1.11 (0.87–1.34) Experienced a needle-stick or sharps injury (ever) from a patient infected with HIV  No 1.00 — — 1.00 — —  Yes 0.79 (0.54–1.09) 0.79 (0.51–1.13) Experienced HIV or HCV testing (ever)  No 1.00 — — 1.00 — —  Yes 0.79 (0.59–1.01) 0.78 (0.55–1.05) Received training related to universal precautions in the last 12 months  No 1.00 — — 1.00 — —  Yes 1.05 (0.84–1.26) 0.99 (0.75–1.23) Wore gloves during all patient care activities  No 1.00 — — 1.00 — —  Yes 1.11 (0.92–1.30) 1.04 (0.83–1.26) I fear transmission from patients infected with HIV  Disagree/somewhat disagree 1.00 — — 1.00 — —  Somewhat agree 0.77 (0.60–0.97) <0.05 0.94 (0.70–1.21)  Agree 0.57 (0.36–0.84) <0.01 0.84 (0.50–1.26) I am confident that I can protect against infection while caring for a patient infected with HIV  Disagree/somewhat disagree 1.00 — — 1.00 — —  Somewhat agree 1.44 (1.09–1.74) <0.05 1.46 (1.06–1.78) <0.05  Agree 1.80 (1.52–2.00) <0.001 1.84 (1.52–2.04) <0.001 I avoid going near people infected with HIV  Disagree/somewhat disagree 1.00 — — 1.00 — —  Somewhat agree 0.49 (0.35–0.68) <0.001 0.52 (0.34–0.76) <0.001  Agree 0.44 (0.23–0.75) <0.001 0.50 (0.23–0.95) <0.05 I link people infected with HIV to homosexuality, injectable drug use or having multiple sex partners  Disagree/somewhat disagree 1.00 — — 1.00 — —  Somewhat agree 0.77 (0.60–0.97) <0.05 0.87 (0.65–1.11)  Agree 0.60 (0.39–0.87) <0.01 0.48 (0.28–0.78) <0.001 I think nurses infected with HIV can continue nursing care if their viral level is low or without high-risk procedures  Disagree/somewhat disagree 1.00 — — 1.00 — —  Somewhat agree 1.41 (1.18–1.62) <0.001 1.52 (1.26–1.75) <0.001  Agree 1.44 (1.18–1.67) <0.001 1.39 (1.08–1.66) <0.05 Univariate OR (95% CI) P Adjusted OR (95% CI) P Age  20–29 years 1.00 — — 1.00 — —  30–39 years 0.69 (0.51–0.91) <0.01 0.70 (0.49–0.94) <0.5  40 years and older 0.61 (0.45–0.81) <0.001 0.51 (0.34–0.74) <0.001 Marital statusa  Married 1.00 — —  Single 1.44 (1.24–1.63) <0.001  Divorced/widowed 0.76 (0.37–1.29) Hospital wards  Internal medicine 1.00 — — 1.00 — —  Surgery/emergency 0.81 (0.57–1.09) 0.84 (0.57–1.15)  Obstetrics/paediatrics 0.66 (0.48–0.88) <0.01 1.00 (0.68–1.35)  Others 0.65 (0.47–0.86) <0.01 0.61 (0.41–0.87) <0.01 Work yearsa  0–9 years 1.00 — —  10–19 years 0.64 (0.46–0.85) <0.001  20 years or more 0.66 (0.48–0.87) <0.01 Cared for a patient infected with HIV in the last 12 months  No 1.00 — — 1.00 — —  Yes 1.17 (0.97–1.36) 1.11 (0.87–1.34) Experienced a needle-stick or sharps injury (ever) from a patient infected with HIV  No 1.00 — — 1.00 — —  Yes 0.79 (0.54–1.09) 0.79 (0.51–1.13) Experienced HIV or HCV testing (ever)  No 1.00 — — 1.00 — —  Yes 0.79 (0.59–1.01) 0.78 (0.55–1.05) Received training related to universal precautions in the last 12 months  No 1.00 — — 1.00 — —  Yes 1.05 (0.84–1.26) 0.99 (0.75–1.23) Wore gloves during all patient care activities  No 1.00 — — 1.00 — —  Yes 1.11 (0.92–1.30) 1.04 (0.83–1.26) I fear transmission from patients infected with HIV  Disagree/somewhat disagree 1.00 — — 1.00 — —  Somewhat agree 0.77 (0.60–0.97) <0.05 0.94 (0.70–1.21)  Agree 0.57 (0.36–0.84) <0.01 0.84 (0.50–1.26) I am confident that I can protect against infection while caring for a patient infected with HIV  Disagree/somewhat disagree 1.00 — — 1.00 — —  Somewhat agree 1.44 (1.09–1.74) <0.05 1.46 (1.06–1.78) <0.05  Agree 1.80 (1.52–2.00) <0.001 1.84 (1.52–2.04) <0.001 I avoid going near people infected with HIV  Disagree/somewhat disagree 1.00 — — 1.00 — —  Somewhat agree 0.49 (0.35–0.68) <0.001 0.52 (0.34–0.76) <0.001  Agree 0.44 (0.23–0.75) <0.001 0.50 (0.23–0.95) <0.05 I link people infected with HIV to homosexuality, injectable drug use or having multiple sex partners  Disagree/somewhat disagree 1.00 — — 1.00 — —  Somewhat agree 0.77 (0.60–0.97) <0.05 0.87 (0.65–1.11)  Agree 0.60 (0.39–0.87) <0.01 0.48 (0.28–0.78) <0.001 I think nurses infected with HIV can continue nursing care if their viral level is low or without high-risk procedures  Disagree/somewhat disagree 1.00 — — 1.00 — —  Somewhat agree 1.41 (1.18–1.62) <0.001 1.52 (1.26–1.75) <0.001  Agree 1.44 (1.18–1.67) <0.001 1.39 (1.08–1.66) <0.05 CI, confidence interval; OR, odds ratio. aMarital status and work years were excluded from the multivariate analysis, because of moderate correlation with age. View Large Table 4. Factors associated with willingness to care for HCV-infected patients Univariate OR (95% CI) P Adjusted OR (95% CI) P Age  20–29 years 1.00 — — 1.00 — —  30–39 years 0.87 (0.65–1.14) 0.86 (0.62–1.15)  40 years and older 0.73 (0.53–0.96) <0.05 0.62 (0.42–0.89) <0.01 Marital statusa  Married 1.00 — —  Single 1.37 (1.13–1.61) <0.01  Divorced/widowed 0.55 (0.24–1.07) Hospital wards  Internal medicine 1.00 — — 1.00 — —  Surgery/emergency 0.92 (0.63–1.25) 0.93 (0.62–1.29)  Obstetrics/paediatrics 0.56 (0.39–0.79) <0.001 0.81 (0.50–1.20)  Others 0.57 (0.40–0.80) <0.001 0.60 (0.38–0.88) <0.01 Work yearsa  0–9 years 1.00 — —  10–19 years 0.86 (0.63–1.13)  20 years or more 0.71 (0.51–0.94) <0.05 Cared for a patient infected with HCV in the last 12 months  No 1.00 — — 1.00 — —  Yes 1.17 (0.95–1.40) 1.00 (0.75–1.28) Experienced a needle-stick or sharps injury (ever) from a patient infected with HCV  No 1.00 — — 1.00 — —  Yes 1.27 (0.80–1.75) 1.26 (0.75–1.79) Experienced HIV or HCV testing (ever)  No 1.00 — — 1.00 — —  Yes 1.15 (0.94–1.38) 1.11 (0.87–1.36) Received training related to universal precautions in the last 12 months  No 1.00 — — 1.00 — —  Yes 1.00 (0.78–1.25) 0.94 (0.70–1.21) Wearing gloves during all patient care activities  No 1.00 — — 1.00 — —  Yes 1.25 (1.03–1.48) <0.05 1.17 (0.93–1.42) I fear transmission from patients infected with HCV  Disagree/somewhat disagree 1.00 — — 1.00 — —  Somewhat agree 0.73 (0.54–0.94) <0.05 0.63 (0.44–0.87) <0.01  Agree 0.69 (0.46–0.98) <0.05 0.63 (0.37–0.99) <0.05 I am confident that I can protect against infection while caring for a patient infected with HCV  Disagree/somewhat disagree 1.00 — — 1.00 — —  Somewhat agree 1.32 (0.93–1.72) 1.34 (0.91–1.76)  Agree 1.90 (1.52–2.18) <0.001 1.87 (1.45–2.18) <0.001 I avoid going near people infected with HCV  Disagree/somewhat disagree 1.00 — — 1.00 — —  Somewhat agree 0.86 (0.61–1.16) 1.15 (0.81–1.52)  Agree 0.48 (0.21–0.98) <0.05 0.77 (0.31–1.49) I link people infected with HCV to homosexuality, injectable drug use or having multiple sex partners  Disagree/somewhat disagree 1.00 — — 1.00 — —  Somewhat agree 0.83 (0.61–1.07) 0.86 (0.62–1.14)  Agree 0.84 (0.51–1.25) 0.72 (0.39–1.18) I think nurses infected with HCV can continue nursing care if their viral level is low or without high-risk procedures  Disagree/somewhat disagree 1.00 — — 1.00 — —  Somewhat agree 1.15 (0.90–1.41) 1.16 (0.89–1.45)  Agree 1.22 (0.92–1.53) 1.16 (0.83–1.50) Univariate OR (95% CI) P Adjusted OR (95% CI) P Age  20–29 years 1.00 — — 1.00 — —  30–39 years 0.87 (0.65–1.14) 0.86 (0.62–1.15)  40 years and older 0.73 (0.53–0.96) <0.05 0.62 (0.42–0.89) <0.01 Marital statusa  Married 1.00 — —  Single 1.37 (1.13–1.61) <0.01  Divorced/widowed 0.55 (0.24–1.07) Hospital wards  Internal medicine 1.00 — — 1.00 — —  Surgery/emergency 0.92 (0.63–1.25) 0.93 (0.62–1.29)  Obstetrics/paediatrics 0.56 (0.39–0.79) <0.001 0.81 (0.50–1.20)  Others 0.57 (0.40–0.80) <0.001 0.60 (0.38–0.88) <0.01 Work yearsa  0–9 years 1.00 — —  10–19 years 0.86 (0.63–1.13)  20 years or more 0.71 (0.51–0.94) <0.05 Cared for a patient infected with HCV in the last 12 months  No 1.00 — — 1.00 — —  Yes 1.17 (0.95–1.40) 1.00 (0.75–1.28) Experienced a needle-stick or sharps injury (ever) from a patient infected with HCV  No 1.00 — — 1.00 — —  Yes 1.27 (0.80–1.75) 1.26 (0.75–1.79) Experienced HIV or HCV testing (ever)  No 1.00 — — 1.00 — —  Yes 1.15 (0.94–1.38) 1.11 (0.87–1.36) Received training related to universal precautions in the last 12 months  No 1.00 — — 1.00 — —  Yes 1.00 (0.78–1.25) 0.94 (0.70–1.21) Wearing gloves during all patient care activities  No 1.00 — — 1.00 — —  Yes 1.25 (1.03–1.48) <0.05 1.17 (0.93–1.42) I fear transmission from patients infected with HCV  Disagree/somewhat disagree 1.00 — — 1.00 — —  Somewhat agree 0.73 (0.54–0.94) <0.05 0.63 (0.44–0.87) <0.01  Agree 0.69 (0.46–0.98) <0.05 0.63 (0.37–0.99) <0.05 I am confident that I can protect against infection while caring for a patient infected with HCV  Disagree/somewhat disagree 1.00 — — 1.00 — —  Somewhat agree 1.32 (0.93–1.72) 1.34 (0.91–1.76)  Agree 1.90 (1.52–2.18) <0.001 1.87 (1.45–2.18) <0.001 I avoid going near people infected with HCV  Disagree/somewhat disagree 1.00 — — 1.00 — —  Somewhat agree 0.86 (0.61–1.16) 1.15 (0.81–1.52)  Agree 0.48 (0.21–0.98) <0.05 0.77 (0.31–1.49) I link people infected with HCV to homosexuality, injectable drug use or having multiple sex partners  Disagree/somewhat disagree 1.00 — — 1.00 — —  Somewhat agree 0.83 (0.61–1.07) 0.86 (0.62–1.14)  Agree 0.84 (0.51–1.25) 0.72 (0.39–1.18) I think nurses infected with HCV can continue nursing care if their viral level is low or without high-risk procedures  Disagree/somewhat disagree 1.00 — — 1.00 — —  Somewhat agree 1.15 (0.90–1.41) 1.16 (0.89–1.45)  Agree 1.22 (0.92–1.53) 1.16 (0.83–1.50) CI, confidence interval; OR, odds ratio. aMarital status and work years were excluded from the multivariate analysis because of moderate correlation with age. View Large Table 4. Factors associated with willingness to care for HCV-infected patients Univariate OR (95% CI) P Adjusted OR (95% CI) P Age  20–29 years 1.00 — — 1.00 — —  30–39 years 0.87 (0.65–1.14) 0.86 (0.62–1.15)  40 years and older 0.73 (0.53–0.96) <0.05 0.62 (0.42–0.89) <0.01 Marital statusa  Married 1.00 — —  Single 1.37 (1.13–1.61) <0.01  Divorced/widowed 0.55 (0.24–1.07) Hospital wards  Internal medicine 1.00 — — 1.00 — —  Surgery/emergency 0.92 (0.63–1.25) 0.93 (0.62–1.29)  Obstetrics/paediatrics 0.56 (0.39–0.79) <0.001 0.81 (0.50–1.20)  Others 0.57 (0.40–0.80) <0.001 0.60 (0.38–0.88) <0.01 Work yearsa  0–9 years 1.00 — —  10–19 years 0.86 (0.63–1.13)  20 years or more 0.71 (0.51–0.94) <0.05 Cared for a patient infected with HCV in the last 12 months  No 1.00 — — 1.00 — —  Yes 1.17 (0.95–1.40) 1.00 (0.75–1.28) Experienced a needle-stick or sharps injury (ever) from a patient infected with HCV  No 1.00 — — 1.00 — —  Yes 1.27 (0.80–1.75) 1.26 (0.75–1.79) Experienced HIV or HCV testing (ever)  No 1.00 — — 1.00 — —  Yes 1.15 (0.94–1.38) 1.11 (0.87–1.36) Received training related to universal precautions in the last 12 months  No 1.00 — — 1.00 — —  Yes 1.00 (0.78–1.25) 0.94 (0.70–1.21) Wearing gloves during all patient care activities  No 1.00 — — 1.00 — —  Yes 1.25 (1.03–1.48) <0.05 1.17 (0.93–1.42) I fear transmission from patients infected with HCV  Disagree/somewhat disagree 1.00 — — 1.00 — —  Somewhat agree 0.73 (0.54–0.94) <0.05 0.63 (0.44–0.87) <0.01  Agree 0.69 (0.46–0.98) <0.05 0.63 (0.37–0.99) <0.05 I am confident that I can protect against infection while caring for a patient infected with HCV  Disagree/somewhat disagree 1.00 — — 1.00 — —  Somewhat agree 1.32 (0.93–1.72) 1.34 (0.91–1.76)  Agree 1.90 (1.52–2.18) <0.001 1.87 (1.45–2.18) <0.001 I avoid going near people infected with HCV  Disagree/somewhat disagree 1.00 — — 1.00 — —  Somewhat agree 0.86 (0.61–1.16) 1.15 (0.81–1.52)  Agree 0.48 (0.21–0.98) <0.05 0.77 (0.31–1.49) I link people infected with HCV to homosexuality, injectable drug use or having multiple sex partners  Disagree/somewhat disagree 1.00 — — 1.00 — —  Somewhat agree 0.83 (0.61–1.07) 0.86 (0.62–1.14)  Agree 0.84 (0.51–1.25) 0.72 (0.39–1.18) I think nurses infected with HCV can continue nursing care if their viral level is low or without high-risk procedures  Disagree/somewhat disagree 1.00 — — 1.00 — —  Somewhat agree 1.15 (0.90–1.41) 1.16 (0.89–1.45)  Agree 1.22 (0.92–1.53) 1.16 (0.83–1.50) Univariate OR (95% CI) P Adjusted OR (95% CI) P Age  20–29 years 1.00 — — 1.00 — —  30–39 years 0.87 (0.65–1.14) 0.86 (0.62–1.15)  40 years and older 0.73 (0.53–0.96) <0.05 0.62 (0.42–0.89) <0.01 Marital statusa  Married 1.00 — —  Single 1.37 (1.13–1.61) <0.01  Divorced/widowed 0.55 (0.24–1.07) Hospital wards  Internal medicine 1.00 — — 1.00 — —  Surgery/emergency 0.92 (0.63–1.25) 0.93 (0.62–1.29)  Obstetrics/paediatrics 0.56 (0.39–0.79) <0.001 0.81 (0.50–1.20)  Others 0.57 (0.40–0.80) <0.001 0.60 (0.38–0.88) <0.01 Work yearsa  0–9 years 1.00 — —  10–19 years 0.86 (0.63–1.13)  20 years or more 0.71 (0.51–0.94) <0.05 Cared for a patient infected with HCV in the last 12 months  No 1.00 — — 1.00 — —  Yes 1.17 (0.95–1.40) 1.00 (0.75–1.28) Experienced a needle-stick or sharps injury (ever) from a patient infected with HCV  No 1.00 — — 1.00 — —  Yes 1.27 (0.80–1.75) 1.26 (0.75–1.79) Experienced HIV or HCV testing (ever)  No 1.00 — — 1.00 — —  Yes 1.15 (0.94–1.38) 1.11 (0.87–1.36) Received training related to universal precautions in the last 12 months  No 1.00 — — 1.00 — —  Yes 1.00 (0.78–1.25) 0.94 (0.70–1.21) Wearing gloves during all patient care activities  No 1.00 — — 1.00 — —  Yes 1.25 (1.03–1.48) <0.05 1.17 (0.93–1.42) I fear transmission from patients infected with HCV  Disagree/somewhat disagree 1.00 — — 1.00 — —  Somewhat agree 0.73 (0.54–0.94) <0.05 0.63 (0.44–0.87) <0.01  Agree 0.69 (0.46–0.98) <0.05 0.63 (0.37–0.99) <0.05 I am confident that I can protect against infection while caring for a patient infected with HCV  Disagree/somewhat disagree 1.00 — — 1.00 — —  Somewhat agree 1.32 (0.93–1.72) 1.34 (0.91–1.76)  Agree 1.90 (1.52–2.18) <0.001 1.87 (1.45–2.18) <0.001 I avoid going near people infected with HCV  Disagree/somewhat disagree 1.00 — — 1.00 — —  Somewhat agree 0.86 (0.61–1.16) 1.15 (0.81–1.52)  Agree 0.48 (0.21–0.98) <0.05 0.77 (0.31–1.49) I link people infected with HCV to homosexuality, injectable drug use or having multiple sex partners  Disagree/somewhat disagree 1.00 — — 1.00 — —  Somewhat agree 0.83 (0.61–1.07) 0.86 (0.62–1.14)  Agree 0.84 (0.51–1.25) 0.72 (0.39–1.18) I think nurses infected with HCV can continue nursing care if their viral level is low or without high-risk procedures  Disagree/somewhat disagree 1.00 — — 1.00 — —  Somewhat agree 1.15 (0.90–1.41) 1.16 (0.89–1.45)  Agree 1.22 (0.92–1.53) 1.16 (0.83–1.50) CI, confidence interval; OR, odds ratio. aMarital status and work years were excluded from the multivariate analysis because of moderate correlation with age. View Large Discussion We found that 44 and 37% of a sample of Thai nurses reported unwillingness to care for HIV- and HCV-infected patients, respectively. Willingness to care was associated with participants’ age, hospital ward, fear of transmission of infection, perception of stigma and discrimination, confidence in protecting against infection and having an accepting attitude towards infected patients. The high response rate was a strength of the study, and the survey instruments had been successfully used in neighbouring Asian countries. We are therefore confident that our questionnaire was well suited for measuring healthcare workers’ attitudes towards individuals with HIV or HCV infection in Asian contexts. This is important, as the perception of stigma and discrimination is often rooted in cultural contexts and historical events [16]. Nevertheless, there are some potential study limitations. Participants can be considered representative of the hospital where they worked in Bangkok, but cannot be truly representative of all Thai nurses. Such limitations are inherent in cross-sectional studies not sampling the entire population. Nurses’ unwillingness to care for HCV-infected patients in our study was relatively higher than that reported in other Asian countries, for example 12% in Iran, 18% in Japan and 27% in Vietnam, despite similar trends in HIV infection [4,5,17]. Our finding that fear of HIV infection was not associated with unwillingness to care was contrary to some previous studies that used a similar methodology [5]. Fear of contagion is known to be a major barrier in providing patient care [17–19]. A potential reason for this might be better knowledge of risk of transmission via occupational exposure (HCV 1.8% versus HIV 0.3%) [20]. However, our results suggest that creating a culture of workplace safety may improve willingness to care by increasing healthcare workers’ confidence in protecting themselves against cross-infection. Minimizing the risk of nosocomial transmission is important for healthcare workers to overcome unwarranted fear of contracting infection. Historically, many common misconceptions have driven HIV-related stigma and discrimination [21]. In this study, nurses’ willingness to care was associated with attitudes of avoiding HIV-infected individuals, as well as prejudices that infected people may have previously engaged in homosexual activity, injectable drug use or have had multiple sex partners. It has been previously reported that moderate levels of HIV knowledge might be insufficient for eliminating nurses’ discriminatory attitudes against those with HIV [22]. Healthcare employers should ensure sufficient HIV education for nurses to facilitate unbiased patient care. Age associations in this study were consistent with previous research [19,23,24], although some investigators found different results attributable to varied social backgrounds [4,5]. One study found younger nurses more willing to care for patients with HCV because of their knowledge and frequent contact with such individuals [19]. Nurses, like anyone, may be influenced by their family members who might consider HIV to represent ‘social evils’ and ask them to reduce contact with infected patients [25,26]. Education on infectious diseases for healthcare workers and communities may improve public perceptions of infected individuals, particularly where cultural beliefs influence such perceptions [27]. This study confirmed a positive relationship between accepting attitudes towards HIV-infected co-workers and subsequent willingness to care for infected patients. This suggests that some nurses consider the human rights of colleagues similar to patients living with HIV. Management of infected healthcare workers using appropriate occupational health systems will be important for not only preventing provider-to-patient transmission, but also for promoting positive attitudes in general [28]. Key points Around 4 in 10 of our sample of Thai nurses were unwilling to care for HIV- or HCV-infected patients. Fear of hepatitis C virus transmission, human immunodeficiency virus-related stigma and discrimination, and age were associated with nurses’ unwillingness to provide care for infected patients. Minimizing the risk of nosocomial transmission and improving the public perception of infected patients may help improve nurses’ willingness to provide care. Funding National Center for Global Health and Medicine, Japan (26-2 and 27-4). Acknowledgement We gratefully acknowledge Mr Amphol Dongnoi for his extensive support in the data collection for this study. Competing interests None declared. References 1. Khuat T , Ashburn K , Pulerwitz J , Ogden J , Nyblade L. 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A consensus for occupational health management of healthcare workers infected with human immunodeficiency virus, hepatitis B virus, and/or hepatitis C virus . J Occup Health 2017 ; 59 : 304 – 308 . Google Scholar CrossRef Search ADS PubMed © The Author(s) 2018. Published by Oxford University Press on behalf of the Society of Occupational Medicine. All rights reserved. For Permissions, please email: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Occupational Medicine Oxford University Press

Willingness to care for blood-borne virus-infected patients in Thailand

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Oxford University Press
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© The Author(s) 2018. Published by Oxford University Press on behalf of the Society of Occupational Medicine. All rights reserved. For Permissions, please email: journals.permissions@oup.com
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0962-7480
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1471-8405
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10.1093/occmed/kqy040
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Abstract

Abstract Background Although stigma and discrimination by nurses against patients infected with human immunodeficiency virus (HIV) or hepatitis C virus (HCV) have been reported, potential determinants of nurses’ willingness to care for these patients have not been well studied in Thailand. Aims To identify factors associated with Thai nurses’ willingness to care for patients infected with HIV or HCV. Methods Multivariable logistic regression analysis of data from a questionnaire completed by nurses at a large hospital in Bangkok, Thailand. Results Of 626 nurses, 546 (87%) nurses participated. Eleven per cent (59) and 6% (34) had previously experienced HIV- or HCV-infected blood contamination incidents, respectively. Forty-four per cent (240) and 38% (208) reported unwillingness to care for HIV- or HCV-infected patients, respectively. Willingness to care was less common [adjusted odds ratios 0.51 (0.34–0.74) for HIV and 0.62 (0.42–0.89) for HCV] in nurses aged ≥ 40 years and in those who feared HCV [0.63 (0.37–0.99)], but not HIV [0.84 (0.5–1.26)] transmission. Nurses who had confidence in protecting themselves against infection with HIV [1.84 (1.52–2.04)] and HCV [1.87 (1.45–2.18)], and accepting attitudes towards HIV-infected co-workers [1.39 (1.08–1.66)] but not HCV-infected co-workers [1.16 (0.83–1.5)], were more willing to care for HIV- and HCV-infected patients. Conclusions Around 4 in 10 Thai nurses in our sample were unwilling to care for HIV- or HCV-infected patients. Minimizing the risk of nosocomial transmission and improving the public perception of infected individuals may help improve nurses’ willingness to care for such patients, in Thailand or elsewhere. Attitude, hepatitis C virus, human immunodeficiency virus, nurses Introduction Healthcare is one of the main areas in which people infected with blood-borne viruses experience discrimination [1]. Hepatitis B infection is preventable, but there is no vaccine against the human immunodeficiency virus (HIV) or hepatitis C virus (HCV). Discrimination by healthcare workers against HIV- or HCV-infected patients can include denial of care, breaches of confidentiality, inappropriate and unethical behaviour and excessive use of precautions [2–5]. In Thailand, in 2013, estimated adult prevalence rates were 1.1% for HIV and 2.7% for HCV [6,7]. Perceived stigma and discrimination against infected patients by healthcare workers have been reported in developed and developing countries [8,9]. However, the literature is scarce regarding potential determinants of willingness to care for these patients in Thailand. This study aimed therefore to identify factors associated with Thai nurses’ willingness to care for HIV- or HCV-infected patients. Methods We used a descriptive, cross-sectional design in our study of nurses at a 1200-bed hospital in Bangkok, one of the largest hospitals in Thailand. The target population was 626 nurses providing direct patient care at the hospital. We excluded male participants because of their small proportion of the overall sample. We adapted a questionnaire from similar investigations undertaken in Japan and Vietnam [4,5,10–12]. We translated the original questionnaire into Thai, using standard translation and back translation [13,14]. The questionnaire had been validated in a series of studies [4,5,10–12] and slightly modified for a Thai context, following consultation with a panel of local healthcare experts. In June 2016, researchers distributed the questionnaire, an information sheet describing the background and study protocol, a consent form and general goods worth about two US dollars as a reward to potential participants through the head nurses in 13 nursing units. Participants completed the questionnaire and consent form, which they placed in a return box, in a sealed envelope, at each nursing unit. Researchers collected the contents of the return boxes for 2 weeks following initial distribution. Ethical approval was granted by the Ethical Review Committee for Human Research, Mahidol University and the Institutional Review Board committee of the hospital. Demographic data collected included age, marital status, hospital ward, work years, training in universal precautions in the preceding 12 months and wearing gloves during all patient care activities (Table 1). Three questions asked whether the participant had cared for an HIV- or HCV-infected patient in the past 12 months, ever personally experienced a needle-stick or other sharps injury while dealing with a patient, or ever personally experienced HIV or HCV testing. Six questions addressed attitudes towards HIV- and HCV-infected patients or colleagues (Table 2). Response options were agree, somewhat agree, somewhat disagree and disagree. Questions about HIV and HCV were asked in a separate section of the questionnaire. Table 1. Demographics of participants (n = 546) n (%) Age  20–29 years 241 (44)  30–39 years 151 (28)  40 years and older 154 (28) Marital status  Married 169 (31)  Single 356 (65)  Divorced/widowed 21 (4) Hospital wards  Internal medicine 130 (24)  Surgery/emergency 131 (24)  Obstetrics/paediatrics 105 (19)  Others 180 (33) Work years  0–9 years 265 (52)  10–19 years 128 (23)  20 years or more 153 (25) Cared for a patient infected with HIV or HCV in the last 12 months  HIV (yes) 342 (63)  HCV (yes) 245 (45) Experienced a needle-stick or sharps injury (ever) from a patient infected with HIV or HCV  HIV (yes) 59 (11)  HCV (yes) 34 (6) Experienced HIV or HCV testing (ever)  HIV (yes) 428 (78)  HCV (yes) 262 (48) Received training related to universal precaution in the last 12 months  Yes 394 (72) Wore gloves during all patient care activities  Yes 267 (49) n (%) Age  20–29 years 241 (44)  30–39 years 151 (28)  40 years and older 154 (28) Marital status  Married 169 (31)  Single 356 (65)  Divorced/widowed 21 (4) Hospital wards  Internal medicine 130 (24)  Surgery/emergency 131 (24)  Obstetrics/paediatrics 105 (19)  Others 180 (33) Work years  0–9 years 265 (52)  10–19 years 128 (23)  20 years or more 153 (25) Cared for a patient infected with HIV or HCV in the last 12 months  HIV (yes) 342 (63)  HCV (yes) 245 (45) Experienced a needle-stick or sharps injury (ever) from a patient infected with HIV or HCV  HIV (yes) 59 (11)  HCV (yes) 34 (6) Experienced HIV or HCV testing (ever)  HIV (yes) 428 (78)  HCV (yes) 262 (48) Received training related to universal precaution in the last 12 months  Yes 394 (72) Wore gloves during all patient care activities  Yes 267 (49) View Large Table 1. Demographics of participants (n = 546) n (%) Age  20–29 years 241 (44)  30–39 years 151 (28)  40 years and older 154 (28) Marital status  Married 169 (31)  Single 356 (65)  Divorced/widowed 21 (4) Hospital wards  Internal medicine 130 (24)  Surgery/emergency 131 (24)  Obstetrics/paediatrics 105 (19)  Others 180 (33) Work years  0–9 years 265 (52)  10–19 years 128 (23)  20 years or more 153 (25) Cared for a patient infected with HIV or HCV in the last 12 months  HIV (yes) 342 (63)  HCV (yes) 245 (45) Experienced a needle-stick or sharps injury (ever) from a patient infected with HIV or HCV  HIV (yes) 59 (11)  HCV (yes) 34 (6) Experienced HIV or HCV testing (ever)  HIV (yes) 428 (78)  HCV (yes) 262 (48) Received training related to universal precaution in the last 12 months  Yes 394 (72) Wore gloves during all patient care activities  Yes 267 (49) n (%) Age  20–29 years 241 (44)  30–39 years 151 (28)  40 years and older 154 (28) Marital status  Married 169 (31)  Single 356 (65)  Divorced/widowed 21 (4) Hospital wards  Internal medicine 130 (24)  Surgery/emergency 131 (24)  Obstetrics/paediatrics 105 (19)  Others 180 (33) Work years  0–9 years 265 (52)  10–19 years 128 (23)  20 years or more 153 (25) Cared for a patient infected with HIV or HCV in the last 12 months  HIV (yes) 342 (63)  HCV (yes) 245 (45) Experienced a needle-stick or sharps injury (ever) from a patient infected with HIV or HCV  HIV (yes) 59 (11)  HCV (yes) 34 (6) Experienced HIV or HCV testing (ever)  HIV (yes) 428 (78)  HCV (yes) 262 (48) Received training related to universal precaution in the last 12 months  Yes 394 (72) Wore gloves during all patient care activities  Yes 267 (49) View Large Table 2 Attitudes towards HIV- and HCV-infected patients (n = 546) HIV, n (%) HCV, n (%) I fear transmission from patients infected with HIV or HCV.  Agree 61 (11) 77 (14)  Somewhat agree 195 (36) 178 (33)  Somewhat disagree 166 (30) 165 (30)  Disagree 124 (23) 126 (23) I am confident that I can protect myself against infection when caring for a patient infected with HIV or HCV.  Agree 238 (44) 251 (46)  Somewhat agree 256 (47) 246 (45)  Somewhat disagree 40 (7) 31 (6)  Disagree 12 (2) 18 (3) I avoid going near people infected with HIV or HCV.  Agree 35 (6) 18 (3)  Somewhat agree 114 (21) 81 (15)  Somewhat disagree 202 (37) 196 (36)  Disagree 196 (36) 251 (46) I link people infected with HIV or HCV to homosexuality, injectable drug use or having multiple sex partners.  Agree 67 (12) 40 (7)  Somewhat agree 232 (43) 128 (24)  Somewhat disagree 149 (27) 182 (33)  Disagree 98 (18) 196 (36) I think nurses infected with HIV or HCV can continue nursing care if their viral level is low or without high-risk procedures.  Agree 142 (26) 130 (24)  Somewhat agree 256 (47) 259 (47)  Somewhat disagree 107 (20) 112 (21)  Disagree 41 (7) 45 (8) I am willing to care for a patient who is infected with HIV or HCV.  Agree 76 (14) 93 (17)  Somewhat agree 230 (42) 245 (45)  Somewhat disagree 176 (32) 159 (29)  Disagree 64 (12) 49 (9) HIV, n (%) HCV, n (%) I fear transmission from patients infected with HIV or HCV.  Agree 61 (11) 77 (14)  Somewhat agree 195 (36) 178 (33)  Somewhat disagree 166 (30) 165 (30)  Disagree 124 (23) 126 (23) I am confident that I can protect myself against infection when caring for a patient infected with HIV or HCV.  Agree 238 (44) 251 (46)  Somewhat agree 256 (47) 246 (45)  Somewhat disagree 40 (7) 31 (6)  Disagree 12 (2) 18 (3) I avoid going near people infected with HIV or HCV.  Agree 35 (6) 18 (3)  Somewhat agree 114 (21) 81 (15)  Somewhat disagree 202 (37) 196 (36)  Disagree 196 (36) 251 (46) I link people infected with HIV or HCV to homosexuality, injectable drug use or having multiple sex partners.  Agree 67 (12) 40 (7)  Somewhat agree 232 (43) 128 (24)  Somewhat disagree 149 (27) 182 (33)  Disagree 98 (18) 196 (36) I think nurses infected with HIV or HCV can continue nursing care if their viral level is low or without high-risk procedures.  Agree 142 (26) 130 (24)  Somewhat agree 256 (47) 259 (47)  Somewhat disagree 107 (20) 112 (21)  Disagree 41 (7) 45 (8) I am willing to care for a patient who is infected with HIV or HCV.  Agree 76 (14) 93 (17)  Somewhat agree 230 (42) 245 (45)  Somewhat disagree 176 (32) 159 (29)  Disagree 64 (12) 49 (9) View Large Table 2 Attitudes towards HIV- and HCV-infected patients (n = 546) HIV, n (%) HCV, n (%) I fear transmission from patients infected with HIV or HCV.  Agree 61 (11) 77 (14)  Somewhat agree 195 (36) 178 (33)  Somewhat disagree 166 (30) 165 (30)  Disagree 124 (23) 126 (23) I am confident that I can protect myself against infection when caring for a patient infected with HIV or HCV.  Agree 238 (44) 251 (46)  Somewhat agree 256 (47) 246 (45)  Somewhat disagree 40 (7) 31 (6)  Disagree 12 (2) 18 (3) I avoid going near people infected with HIV or HCV.  Agree 35 (6) 18 (3)  Somewhat agree 114 (21) 81 (15)  Somewhat disagree 202 (37) 196 (36)  Disagree 196 (36) 251 (46) I link people infected with HIV or HCV to homosexuality, injectable drug use or having multiple sex partners.  Agree 67 (12) 40 (7)  Somewhat agree 232 (43) 128 (24)  Somewhat disagree 149 (27) 182 (33)  Disagree 98 (18) 196 (36) I think nurses infected with HIV or HCV can continue nursing care if their viral level is low or without high-risk procedures.  Agree 142 (26) 130 (24)  Somewhat agree 256 (47) 259 (47)  Somewhat disagree 107 (20) 112 (21)  Disagree 41 (7) 45 (8) I am willing to care for a patient who is infected with HIV or HCV.  Agree 76 (14) 93 (17)  Somewhat agree 230 (42) 245 (45)  Somewhat disagree 176 (32) 159 (29)  Disagree 64 (12) 49 (9) HIV, n (%) HCV, n (%) I fear transmission from patients infected with HIV or HCV.  Agree 61 (11) 77 (14)  Somewhat agree 195 (36) 178 (33)  Somewhat disagree 166 (30) 165 (30)  Disagree 124 (23) 126 (23) I am confident that I can protect myself against infection when caring for a patient infected with HIV or HCV.  Agree 238 (44) 251 (46)  Somewhat agree 256 (47) 246 (45)  Somewhat disagree 40 (7) 31 (6)  Disagree 12 (2) 18 (3) I avoid going near people infected with HIV or HCV.  Agree 35 (6) 18 (3)  Somewhat agree 114 (21) 81 (15)  Somewhat disagree 202 (37) 196 (36)  Disagree 196 (36) 251 (46) I link people infected with HIV or HCV to homosexuality, injectable drug use or having multiple sex partners.  Agree 67 (12) 40 (7)  Somewhat agree 232 (43) 128 (24)  Somewhat disagree 149 (27) 182 (33)  Disagree 98 (18) 196 (36) I think nurses infected with HIV or HCV can continue nursing care if their viral level is low or without high-risk procedures.  Agree 142 (26) 130 (24)  Somewhat agree 256 (47) 259 (47)  Somewhat disagree 107 (20) 112 (21)  Disagree 41 (7) 45 (8) I am willing to care for a patient who is infected with HIV or HCV.  Agree 76 (14) 93 (17)  Somewhat agree 230 (42) 245 (45)  Somewhat disagree 176 (32) 159 (29)  Disagree 64 (12) 49 (9) View Large We conducted univariate statistical analysis to estimate odds ratios and 95% confidence intervals for all variables, to identify factors associated with willingness to care for HIV- or HCV-infected patients. We subsequently undertook multivariable logistic regression using Zhang’s formula to adjust for age, hospital ward, training, wearing gloves, patient care, needle-stick or other sharps injury, and testing, given the common prevalence of these variables [15]. We excluded marital status and work years from the multivariate analysis because of their moderate correlation with age. For the statistical analysis, we categorized responses about attitudes into three groups (1 = agree, 2 = somewhat agree and 3 = disagree/somewhat disagree), and two groups for outcomes (1 = agree/somewhat agree and 2 = disagree/somewhat disagree). We used SPSS Statistics for Windows, Version 17.0 (SPSS Inc., Chicago, IL, USA) for the analyses. We used two-sided statistical tests and considered probability (P) values < 0.05 statistically significant. Results Five hundred and forty-six (546/626) nurses returned valid, completed questionnaires (response rate: 87%), 2% (14) did not participate, 10% (60) returned uncompleted questionnaires and 1% (6) were male. Demographic data for participants, their experience of caring for HIV- or HCV-infected patients and their experience of HIV or HCV exposure incidents are shown in Table 1. Participants’ attitudes towards HIV- and HCV-infected patients and colleagues, and their confidence in protecting themselves against infection are shown in Table 2. Tables 3 and 4 indicate factors associated with willingness to care for HIV- and HCV-infected patients, respectively. Negative determinants of willingness to care were as follows: age ≥ 40, wards other than internal medicine, those who feared HCV, avoiding HIV-infected patients and associating HIV infection with homosexuality, injectable drug use or having multiple sex partners. Willingness to care was positively associated with confidence in protection against infection when caring for infected patients. Accepting attitudes towards infected co-workers having contact with patients was associated with willingness to care for HIV-infected patients but not HCV-infected patients. Nurses who had confidence in protecting themselves against infection with HIV and HCV, and accepting attitudes towards HIV-infected co-workers but not HCV-infected co-workers, were more willing to care for HIV- and HCV-infected patients. Table 3. Factors associated with willingness to care for HIV-infected patients Univariate OR (95% CI) P Adjusted OR (95% CI) P Age  20–29 years 1.00 — — 1.00 — —  30–39 years 0.69 (0.51–0.91) <0.01 0.70 (0.49–0.94) <0.5  40 years and older 0.61 (0.45–0.81) <0.001 0.51 (0.34–0.74) <0.001 Marital statusa  Married 1.00 — —  Single 1.44 (1.24–1.63) <0.001  Divorced/widowed 0.76 (0.37–1.29) Hospital wards  Internal medicine 1.00 — — 1.00 — —  Surgery/emergency 0.81 (0.57–1.09) 0.84 (0.57–1.15)  Obstetrics/paediatrics 0.66 (0.48–0.88) <0.01 1.00 (0.68–1.35)  Others 0.65 (0.47–0.86) <0.01 0.61 (0.41–0.87) <0.01 Work yearsa  0–9 years 1.00 — —  10–19 years 0.64 (0.46–0.85) <0.001  20 years or more 0.66 (0.48–0.87) <0.01 Cared for a patient infected with HIV in the last 12 months  No 1.00 — — 1.00 — —  Yes 1.17 (0.97–1.36) 1.11 (0.87–1.34) Experienced a needle-stick or sharps injury (ever) from a patient infected with HIV  No 1.00 — — 1.00 — —  Yes 0.79 (0.54–1.09) 0.79 (0.51–1.13) Experienced HIV or HCV testing (ever)  No 1.00 — — 1.00 — —  Yes 0.79 (0.59–1.01) 0.78 (0.55–1.05) Received training related to universal precautions in the last 12 months  No 1.00 — — 1.00 — —  Yes 1.05 (0.84–1.26) 0.99 (0.75–1.23) Wore gloves during all patient care activities  No 1.00 — — 1.00 — —  Yes 1.11 (0.92–1.30) 1.04 (0.83–1.26) I fear transmission from patients infected with HIV  Disagree/somewhat disagree 1.00 — — 1.00 — —  Somewhat agree 0.77 (0.60–0.97) <0.05 0.94 (0.70–1.21)  Agree 0.57 (0.36–0.84) <0.01 0.84 (0.50–1.26) I am confident that I can protect against infection while caring for a patient infected with HIV  Disagree/somewhat disagree 1.00 — — 1.00 — —  Somewhat agree 1.44 (1.09–1.74) <0.05 1.46 (1.06–1.78) <0.05  Agree 1.80 (1.52–2.00) <0.001 1.84 (1.52–2.04) <0.001 I avoid going near people infected with HIV  Disagree/somewhat disagree 1.00 — — 1.00 — —  Somewhat agree 0.49 (0.35–0.68) <0.001 0.52 (0.34–0.76) <0.001  Agree 0.44 (0.23–0.75) <0.001 0.50 (0.23–0.95) <0.05 I link people infected with HIV to homosexuality, injectable drug use or having multiple sex partners  Disagree/somewhat disagree 1.00 — — 1.00 — —  Somewhat agree 0.77 (0.60–0.97) <0.05 0.87 (0.65–1.11)  Agree 0.60 (0.39–0.87) <0.01 0.48 (0.28–0.78) <0.001 I think nurses infected with HIV can continue nursing care if their viral level is low or without high-risk procedures  Disagree/somewhat disagree 1.00 — — 1.00 — —  Somewhat agree 1.41 (1.18–1.62) <0.001 1.52 (1.26–1.75) <0.001  Agree 1.44 (1.18–1.67) <0.001 1.39 (1.08–1.66) <0.05 Univariate OR (95% CI) P Adjusted OR (95% CI) P Age  20–29 years 1.00 — — 1.00 — —  30–39 years 0.69 (0.51–0.91) <0.01 0.70 (0.49–0.94) <0.5  40 years and older 0.61 (0.45–0.81) <0.001 0.51 (0.34–0.74) <0.001 Marital statusa  Married 1.00 — —  Single 1.44 (1.24–1.63) <0.001  Divorced/widowed 0.76 (0.37–1.29) Hospital wards  Internal medicine 1.00 — — 1.00 — —  Surgery/emergency 0.81 (0.57–1.09) 0.84 (0.57–1.15)  Obstetrics/paediatrics 0.66 (0.48–0.88) <0.01 1.00 (0.68–1.35)  Others 0.65 (0.47–0.86) <0.01 0.61 (0.41–0.87) <0.01 Work yearsa  0–9 years 1.00 — —  10–19 years 0.64 (0.46–0.85) <0.001  20 years or more 0.66 (0.48–0.87) <0.01 Cared for a patient infected with HIV in the last 12 months  No 1.00 — — 1.00 — —  Yes 1.17 (0.97–1.36) 1.11 (0.87–1.34) Experienced a needle-stick or sharps injury (ever) from a patient infected with HIV  No 1.00 — — 1.00 — —  Yes 0.79 (0.54–1.09) 0.79 (0.51–1.13) Experienced HIV or HCV testing (ever)  No 1.00 — — 1.00 — —  Yes 0.79 (0.59–1.01) 0.78 (0.55–1.05) Received training related to universal precautions in the last 12 months  No 1.00 — — 1.00 — —  Yes 1.05 (0.84–1.26) 0.99 (0.75–1.23) Wore gloves during all patient care activities  No 1.00 — — 1.00 — —  Yes 1.11 (0.92–1.30) 1.04 (0.83–1.26) I fear transmission from patients infected with HIV  Disagree/somewhat disagree 1.00 — — 1.00 — —  Somewhat agree 0.77 (0.60–0.97) <0.05 0.94 (0.70–1.21)  Agree 0.57 (0.36–0.84) <0.01 0.84 (0.50–1.26) I am confident that I can protect against infection while caring for a patient infected with HIV  Disagree/somewhat disagree 1.00 — — 1.00 — —  Somewhat agree 1.44 (1.09–1.74) <0.05 1.46 (1.06–1.78) <0.05  Agree 1.80 (1.52–2.00) <0.001 1.84 (1.52–2.04) <0.001 I avoid going near people infected with HIV  Disagree/somewhat disagree 1.00 — — 1.00 — —  Somewhat agree 0.49 (0.35–0.68) <0.001 0.52 (0.34–0.76) <0.001  Agree 0.44 (0.23–0.75) <0.001 0.50 (0.23–0.95) <0.05 I link people infected with HIV to homosexuality, injectable drug use or having multiple sex partners  Disagree/somewhat disagree 1.00 — — 1.00 — —  Somewhat agree 0.77 (0.60–0.97) <0.05 0.87 (0.65–1.11)  Agree 0.60 (0.39–0.87) <0.01 0.48 (0.28–0.78) <0.001 I think nurses infected with HIV can continue nursing care if their viral level is low or without high-risk procedures  Disagree/somewhat disagree 1.00 — — 1.00 — —  Somewhat agree 1.41 (1.18–1.62) <0.001 1.52 (1.26–1.75) <0.001  Agree 1.44 (1.18–1.67) <0.001 1.39 (1.08–1.66) <0.05 CI, confidence interval; OR, odds ratio. aMarital status and work years were excluded from the multivariate analysis, because of moderate correlation with age. View Large Table 3. Factors associated with willingness to care for HIV-infected patients Univariate OR (95% CI) P Adjusted OR (95% CI) P Age  20–29 years 1.00 — — 1.00 — —  30–39 years 0.69 (0.51–0.91) <0.01 0.70 (0.49–0.94) <0.5  40 years and older 0.61 (0.45–0.81) <0.001 0.51 (0.34–0.74) <0.001 Marital statusa  Married 1.00 — —  Single 1.44 (1.24–1.63) <0.001  Divorced/widowed 0.76 (0.37–1.29) Hospital wards  Internal medicine 1.00 — — 1.00 — —  Surgery/emergency 0.81 (0.57–1.09) 0.84 (0.57–1.15)  Obstetrics/paediatrics 0.66 (0.48–0.88) <0.01 1.00 (0.68–1.35)  Others 0.65 (0.47–0.86) <0.01 0.61 (0.41–0.87) <0.01 Work yearsa  0–9 years 1.00 — —  10–19 years 0.64 (0.46–0.85) <0.001  20 years or more 0.66 (0.48–0.87) <0.01 Cared for a patient infected with HIV in the last 12 months  No 1.00 — — 1.00 — —  Yes 1.17 (0.97–1.36) 1.11 (0.87–1.34) Experienced a needle-stick or sharps injury (ever) from a patient infected with HIV  No 1.00 — — 1.00 — —  Yes 0.79 (0.54–1.09) 0.79 (0.51–1.13) Experienced HIV or HCV testing (ever)  No 1.00 — — 1.00 — —  Yes 0.79 (0.59–1.01) 0.78 (0.55–1.05) Received training related to universal precautions in the last 12 months  No 1.00 — — 1.00 — —  Yes 1.05 (0.84–1.26) 0.99 (0.75–1.23) Wore gloves during all patient care activities  No 1.00 — — 1.00 — —  Yes 1.11 (0.92–1.30) 1.04 (0.83–1.26) I fear transmission from patients infected with HIV  Disagree/somewhat disagree 1.00 — — 1.00 — —  Somewhat agree 0.77 (0.60–0.97) <0.05 0.94 (0.70–1.21)  Agree 0.57 (0.36–0.84) <0.01 0.84 (0.50–1.26) I am confident that I can protect against infection while caring for a patient infected with HIV  Disagree/somewhat disagree 1.00 — — 1.00 — —  Somewhat agree 1.44 (1.09–1.74) <0.05 1.46 (1.06–1.78) <0.05  Agree 1.80 (1.52–2.00) <0.001 1.84 (1.52–2.04) <0.001 I avoid going near people infected with HIV  Disagree/somewhat disagree 1.00 — — 1.00 — —  Somewhat agree 0.49 (0.35–0.68) <0.001 0.52 (0.34–0.76) <0.001  Agree 0.44 (0.23–0.75) <0.001 0.50 (0.23–0.95) <0.05 I link people infected with HIV to homosexuality, injectable drug use or having multiple sex partners  Disagree/somewhat disagree 1.00 — — 1.00 — —  Somewhat agree 0.77 (0.60–0.97) <0.05 0.87 (0.65–1.11)  Agree 0.60 (0.39–0.87) <0.01 0.48 (0.28–0.78) <0.001 I think nurses infected with HIV can continue nursing care if their viral level is low or without high-risk procedures  Disagree/somewhat disagree 1.00 — — 1.00 — —  Somewhat agree 1.41 (1.18–1.62) <0.001 1.52 (1.26–1.75) <0.001  Agree 1.44 (1.18–1.67) <0.001 1.39 (1.08–1.66) <0.05 Univariate OR (95% CI) P Adjusted OR (95% CI) P Age  20–29 years 1.00 — — 1.00 — —  30–39 years 0.69 (0.51–0.91) <0.01 0.70 (0.49–0.94) <0.5  40 years and older 0.61 (0.45–0.81) <0.001 0.51 (0.34–0.74) <0.001 Marital statusa  Married 1.00 — —  Single 1.44 (1.24–1.63) <0.001  Divorced/widowed 0.76 (0.37–1.29) Hospital wards  Internal medicine 1.00 — — 1.00 — —  Surgery/emergency 0.81 (0.57–1.09) 0.84 (0.57–1.15)  Obstetrics/paediatrics 0.66 (0.48–0.88) <0.01 1.00 (0.68–1.35)  Others 0.65 (0.47–0.86) <0.01 0.61 (0.41–0.87) <0.01 Work yearsa  0–9 years 1.00 — —  10–19 years 0.64 (0.46–0.85) <0.001  20 years or more 0.66 (0.48–0.87) <0.01 Cared for a patient infected with HIV in the last 12 months  No 1.00 — — 1.00 — —  Yes 1.17 (0.97–1.36) 1.11 (0.87–1.34) Experienced a needle-stick or sharps injury (ever) from a patient infected with HIV  No 1.00 — — 1.00 — —  Yes 0.79 (0.54–1.09) 0.79 (0.51–1.13) Experienced HIV or HCV testing (ever)  No 1.00 — — 1.00 — —  Yes 0.79 (0.59–1.01) 0.78 (0.55–1.05) Received training related to universal precautions in the last 12 months  No 1.00 — — 1.00 — —  Yes 1.05 (0.84–1.26) 0.99 (0.75–1.23) Wore gloves during all patient care activities  No 1.00 — — 1.00 — —  Yes 1.11 (0.92–1.30) 1.04 (0.83–1.26) I fear transmission from patients infected with HIV  Disagree/somewhat disagree 1.00 — — 1.00 — —  Somewhat agree 0.77 (0.60–0.97) <0.05 0.94 (0.70–1.21)  Agree 0.57 (0.36–0.84) <0.01 0.84 (0.50–1.26) I am confident that I can protect against infection while caring for a patient infected with HIV  Disagree/somewhat disagree 1.00 — — 1.00 — —  Somewhat agree 1.44 (1.09–1.74) <0.05 1.46 (1.06–1.78) <0.05  Agree 1.80 (1.52–2.00) <0.001 1.84 (1.52–2.04) <0.001 I avoid going near people infected with HIV  Disagree/somewhat disagree 1.00 — — 1.00 — —  Somewhat agree 0.49 (0.35–0.68) <0.001 0.52 (0.34–0.76) <0.001  Agree 0.44 (0.23–0.75) <0.001 0.50 (0.23–0.95) <0.05 I link people infected with HIV to homosexuality, injectable drug use or having multiple sex partners  Disagree/somewhat disagree 1.00 — — 1.00 — —  Somewhat agree 0.77 (0.60–0.97) <0.05 0.87 (0.65–1.11)  Agree 0.60 (0.39–0.87) <0.01 0.48 (0.28–0.78) <0.001 I think nurses infected with HIV can continue nursing care if their viral level is low or without high-risk procedures  Disagree/somewhat disagree 1.00 — — 1.00 — —  Somewhat agree 1.41 (1.18–1.62) <0.001 1.52 (1.26–1.75) <0.001  Agree 1.44 (1.18–1.67) <0.001 1.39 (1.08–1.66) <0.05 CI, confidence interval; OR, odds ratio. aMarital status and work years were excluded from the multivariate analysis, because of moderate correlation with age. View Large Table 4. Factors associated with willingness to care for HCV-infected patients Univariate OR (95% CI) P Adjusted OR (95% CI) P Age  20–29 years 1.00 — — 1.00 — —  30–39 years 0.87 (0.65–1.14) 0.86 (0.62–1.15)  40 years and older 0.73 (0.53–0.96) <0.05 0.62 (0.42–0.89) <0.01 Marital statusa  Married 1.00 — —  Single 1.37 (1.13–1.61) <0.01  Divorced/widowed 0.55 (0.24–1.07) Hospital wards  Internal medicine 1.00 — — 1.00 — —  Surgery/emergency 0.92 (0.63–1.25) 0.93 (0.62–1.29)  Obstetrics/paediatrics 0.56 (0.39–0.79) <0.001 0.81 (0.50–1.20)  Others 0.57 (0.40–0.80) <0.001 0.60 (0.38–0.88) <0.01 Work yearsa  0–9 years 1.00 — —  10–19 years 0.86 (0.63–1.13)  20 years or more 0.71 (0.51–0.94) <0.05 Cared for a patient infected with HCV in the last 12 months  No 1.00 — — 1.00 — —  Yes 1.17 (0.95–1.40) 1.00 (0.75–1.28) Experienced a needle-stick or sharps injury (ever) from a patient infected with HCV  No 1.00 — — 1.00 — —  Yes 1.27 (0.80–1.75) 1.26 (0.75–1.79) Experienced HIV or HCV testing (ever)  No 1.00 — — 1.00 — —  Yes 1.15 (0.94–1.38) 1.11 (0.87–1.36) Received training related to universal precautions in the last 12 months  No 1.00 — — 1.00 — —  Yes 1.00 (0.78–1.25) 0.94 (0.70–1.21) Wearing gloves during all patient care activities  No 1.00 — — 1.00 — —  Yes 1.25 (1.03–1.48) <0.05 1.17 (0.93–1.42) I fear transmission from patients infected with HCV  Disagree/somewhat disagree 1.00 — — 1.00 — —  Somewhat agree 0.73 (0.54–0.94) <0.05 0.63 (0.44–0.87) <0.01  Agree 0.69 (0.46–0.98) <0.05 0.63 (0.37–0.99) <0.05 I am confident that I can protect against infection while caring for a patient infected with HCV  Disagree/somewhat disagree 1.00 — — 1.00 — —  Somewhat agree 1.32 (0.93–1.72) 1.34 (0.91–1.76)  Agree 1.90 (1.52–2.18) <0.001 1.87 (1.45–2.18) <0.001 I avoid going near people infected with HCV  Disagree/somewhat disagree 1.00 — — 1.00 — —  Somewhat agree 0.86 (0.61–1.16) 1.15 (0.81–1.52)  Agree 0.48 (0.21–0.98) <0.05 0.77 (0.31–1.49) I link people infected with HCV to homosexuality, injectable drug use or having multiple sex partners  Disagree/somewhat disagree 1.00 — — 1.00 — —  Somewhat agree 0.83 (0.61–1.07) 0.86 (0.62–1.14)  Agree 0.84 (0.51–1.25) 0.72 (0.39–1.18) I think nurses infected with HCV can continue nursing care if their viral level is low or without high-risk procedures  Disagree/somewhat disagree 1.00 — — 1.00 — —  Somewhat agree 1.15 (0.90–1.41) 1.16 (0.89–1.45)  Agree 1.22 (0.92–1.53) 1.16 (0.83–1.50) Univariate OR (95% CI) P Adjusted OR (95% CI) P Age  20–29 years 1.00 — — 1.00 — —  30–39 years 0.87 (0.65–1.14) 0.86 (0.62–1.15)  40 years and older 0.73 (0.53–0.96) <0.05 0.62 (0.42–0.89) <0.01 Marital statusa  Married 1.00 — —  Single 1.37 (1.13–1.61) <0.01  Divorced/widowed 0.55 (0.24–1.07) Hospital wards  Internal medicine 1.00 — — 1.00 — —  Surgery/emergency 0.92 (0.63–1.25) 0.93 (0.62–1.29)  Obstetrics/paediatrics 0.56 (0.39–0.79) <0.001 0.81 (0.50–1.20)  Others 0.57 (0.40–0.80) <0.001 0.60 (0.38–0.88) <0.01 Work yearsa  0–9 years 1.00 — —  10–19 years 0.86 (0.63–1.13)  20 years or more 0.71 (0.51–0.94) <0.05 Cared for a patient infected with HCV in the last 12 months  No 1.00 — — 1.00 — —  Yes 1.17 (0.95–1.40) 1.00 (0.75–1.28) Experienced a needle-stick or sharps injury (ever) from a patient infected with HCV  No 1.00 — — 1.00 — —  Yes 1.27 (0.80–1.75) 1.26 (0.75–1.79) Experienced HIV or HCV testing (ever)  No 1.00 — — 1.00 — —  Yes 1.15 (0.94–1.38) 1.11 (0.87–1.36) Received training related to universal precautions in the last 12 months  No 1.00 — — 1.00 — —  Yes 1.00 (0.78–1.25) 0.94 (0.70–1.21) Wearing gloves during all patient care activities  No 1.00 — — 1.00 — —  Yes 1.25 (1.03–1.48) <0.05 1.17 (0.93–1.42) I fear transmission from patients infected with HCV  Disagree/somewhat disagree 1.00 — — 1.00 — —  Somewhat agree 0.73 (0.54–0.94) <0.05 0.63 (0.44–0.87) <0.01  Agree 0.69 (0.46–0.98) <0.05 0.63 (0.37–0.99) <0.05 I am confident that I can protect against infection while caring for a patient infected with HCV  Disagree/somewhat disagree 1.00 — — 1.00 — —  Somewhat agree 1.32 (0.93–1.72) 1.34 (0.91–1.76)  Agree 1.90 (1.52–2.18) <0.001 1.87 (1.45–2.18) <0.001 I avoid going near people infected with HCV  Disagree/somewhat disagree 1.00 — — 1.00 — —  Somewhat agree 0.86 (0.61–1.16) 1.15 (0.81–1.52)  Agree 0.48 (0.21–0.98) <0.05 0.77 (0.31–1.49) I link people infected with HCV to homosexuality, injectable drug use or having multiple sex partners  Disagree/somewhat disagree 1.00 — — 1.00 — —  Somewhat agree 0.83 (0.61–1.07) 0.86 (0.62–1.14)  Agree 0.84 (0.51–1.25) 0.72 (0.39–1.18) I think nurses infected with HCV can continue nursing care if their viral level is low or without high-risk procedures  Disagree/somewhat disagree 1.00 — — 1.00 — —  Somewhat agree 1.15 (0.90–1.41) 1.16 (0.89–1.45)  Agree 1.22 (0.92–1.53) 1.16 (0.83–1.50) CI, confidence interval; OR, odds ratio. aMarital status and work years were excluded from the multivariate analysis because of moderate correlation with age. View Large Table 4. Factors associated with willingness to care for HCV-infected patients Univariate OR (95% CI) P Adjusted OR (95% CI) P Age  20–29 years 1.00 — — 1.00 — —  30–39 years 0.87 (0.65–1.14) 0.86 (0.62–1.15)  40 years and older 0.73 (0.53–0.96) <0.05 0.62 (0.42–0.89) <0.01 Marital statusa  Married 1.00 — —  Single 1.37 (1.13–1.61) <0.01  Divorced/widowed 0.55 (0.24–1.07) Hospital wards  Internal medicine 1.00 — — 1.00 — —  Surgery/emergency 0.92 (0.63–1.25) 0.93 (0.62–1.29)  Obstetrics/paediatrics 0.56 (0.39–0.79) <0.001 0.81 (0.50–1.20)  Others 0.57 (0.40–0.80) <0.001 0.60 (0.38–0.88) <0.01 Work yearsa  0–9 years 1.00 — —  10–19 years 0.86 (0.63–1.13)  20 years or more 0.71 (0.51–0.94) <0.05 Cared for a patient infected with HCV in the last 12 months  No 1.00 — — 1.00 — —  Yes 1.17 (0.95–1.40) 1.00 (0.75–1.28) Experienced a needle-stick or sharps injury (ever) from a patient infected with HCV  No 1.00 — — 1.00 — —  Yes 1.27 (0.80–1.75) 1.26 (0.75–1.79) Experienced HIV or HCV testing (ever)  No 1.00 — — 1.00 — —  Yes 1.15 (0.94–1.38) 1.11 (0.87–1.36) Received training related to universal precautions in the last 12 months  No 1.00 — — 1.00 — —  Yes 1.00 (0.78–1.25) 0.94 (0.70–1.21) Wearing gloves during all patient care activities  No 1.00 — — 1.00 — —  Yes 1.25 (1.03–1.48) <0.05 1.17 (0.93–1.42) I fear transmission from patients infected with HCV  Disagree/somewhat disagree 1.00 — — 1.00 — —  Somewhat agree 0.73 (0.54–0.94) <0.05 0.63 (0.44–0.87) <0.01  Agree 0.69 (0.46–0.98) <0.05 0.63 (0.37–0.99) <0.05 I am confident that I can protect against infection while caring for a patient infected with HCV  Disagree/somewhat disagree 1.00 — — 1.00 — —  Somewhat agree 1.32 (0.93–1.72) 1.34 (0.91–1.76)  Agree 1.90 (1.52–2.18) <0.001 1.87 (1.45–2.18) <0.001 I avoid going near people infected with HCV  Disagree/somewhat disagree 1.00 — — 1.00 — —  Somewhat agree 0.86 (0.61–1.16) 1.15 (0.81–1.52)  Agree 0.48 (0.21–0.98) <0.05 0.77 (0.31–1.49) I link people infected with HCV to homosexuality, injectable drug use or having multiple sex partners  Disagree/somewhat disagree 1.00 — — 1.00 — —  Somewhat agree 0.83 (0.61–1.07) 0.86 (0.62–1.14)  Agree 0.84 (0.51–1.25) 0.72 (0.39–1.18) I think nurses infected with HCV can continue nursing care if their viral level is low or without high-risk procedures  Disagree/somewhat disagree 1.00 — — 1.00 — —  Somewhat agree 1.15 (0.90–1.41) 1.16 (0.89–1.45)  Agree 1.22 (0.92–1.53) 1.16 (0.83–1.50) Univariate OR (95% CI) P Adjusted OR (95% CI) P Age  20–29 years 1.00 — — 1.00 — —  30–39 years 0.87 (0.65–1.14) 0.86 (0.62–1.15)  40 years and older 0.73 (0.53–0.96) <0.05 0.62 (0.42–0.89) <0.01 Marital statusa  Married 1.00 — —  Single 1.37 (1.13–1.61) <0.01  Divorced/widowed 0.55 (0.24–1.07) Hospital wards  Internal medicine 1.00 — — 1.00 — —  Surgery/emergency 0.92 (0.63–1.25) 0.93 (0.62–1.29)  Obstetrics/paediatrics 0.56 (0.39–0.79) <0.001 0.81 (0.50–1.20)  Others 0.57 (0.40–0.80) <0.001 0.60 (0.38–0.88) <0.01 Work yearsa  0–9 years 1.00 — —  10–19 years 0.86 (0.63–1.13)  20 years or more 0.71 (0.51–0.94) <0.05 Cared for a patient infected with HCV in the last 12 months  No 1.00 — — 1.00 — —  Yes 1.17 (0.95–1.40) 1.00 (0.75–1.28) Experienced a needle-stick or sharps injury (ever) from a patient infected with HCV  No 1.00 — — 1.00 — —  Yes 1.27 (0.80–1.75) 1.26 (0.75–1.79) Experienced HIV or HCV testing (ever)  No 1.00 — — 1.00 — —  Yes 1.15 (0.94–1.38) 1.11 (0.87–1.36) Received training related to universal precautions in the last 12 months  No 1.00 — — 1.00 — —  Yes 1.00 (0.78–1.25) 0.94 (0.70–1.21) Wearing gloves during all patient care activities  No 1.00 — — 1.00 — —  Yes 1.25 (1.03–1.48) <0.05 1.17 (0.93–1.42) I fear transmission from patients infected with HCV  Disagree/somewhat disagree 1.00 — — 1.00 — —  Somewhat agree 0.73 (0.54–0.94) <0.05 0.63 (0.44–0.87) <0.01  Agree 0.69 (0.46–0.98) <0.05 0.63 (0.37–0.99) <0.05 I am confident that I can protect against infection while caring for a patient infected with HCV  Disagree/somewhat disagree 1.00 — — 1.00 — —  Somewhat agree 1.32 (0.93–1.72) 1.34 (0.91–1.76)  Agree 1.90 (1.52–2.18) <0.001 1.87 (1.45–2.18) <0.001 I avoid going near people infected with HCV  Disagree/somewhat disagree 1.00 — — 1.00 — —  Somewhat agree 0.86 (0.61–1.16) 1.15 (0.81–1.52)  Agree 0.48 (0.21–0.98) <0.05 0.77 (0.31–1.49) I link people infected with HCV to homosexuality, injectable drug use or having multiple sex partners  Disagree/somewhat disagree 1.00 — — 1.00 — —  Somewhat agree 0.83 (0.61–1.07) 0.86 (0.62–1.14)  Agree 0.84 (0.51–1.25) 0.72 (0.39–1.18) I think nurses infected with HCV can continue nursing care if their viral level is low or without high-risk procedures  Disagree/somewhat disagree 1.00 — — 1.00 — —  Somewhat agree 1.15 (0.90–1.41) 1.16 (0.89–1.45)  Agree 1.22 (0.92–1.53) 1.16 (0.83–1.50) CI, confidence interval; OR, odds ratio. aMarital status and work years were excluded from the multivariate analysis because of moderate correlation with age. View Large Discussion We found that 44 and 37% of a sample of Thai nurses reported unwillingness to care for HIV- and HCV-infected patients, respectively. Willingness to care was associated with participants’ age, hospital ward, fear of transmission of infection, perception of stigma and discrimination, confidence in protecting against infection and having an accepting attitude towards infected patients. The high response rate was a strength of the study, and the survey instruments had been successfully used in neighbouring Asian countries. We are therefore confident that our questionnaire was well suited for measuring healthcare workers’ attitudes towards individuals with HIV or HCV infection in Asian contexts. This is important, as the perception of stigma and discrimination is often rooted in cultural contexts and historical events [16]. Nevertheless, there are some potential study limitations. Participants can be considered representative of the hospital where they worked in Bangkok, but cannot be truly representative of all Thai nurses. Such limitations are inherent in cross-sectional studies not sampling the entire population. Nurses’ unwillingness to care for HCV-infected patients in our study was relatively higher than that reported in other Asian countries, for example 12% in Iran, 18% in Japan and 27% in Vietnam, despite similar trends in HIV infection [4,5,17]. Our finding that fear of HIV infection was not associated with unwillingness to care was contrary to some previous studies that used a similar methodology [5]. Fear of contagion is known to be a major barrier in providing patient care [17–19]. A potential reason for this might be better knowledge of risk of transmission via occupational exposure (HCV 1.8% versus HIV 0.3%) [20]. However, our results suggest that creating a culture of workplace safety may improve willingness to care by increasing healthcare workers’ confidence in protecting themselves against cross-infection. Minimizing the risk of nosocomial transmission is important for healthcare workers to overcome unwarranted fear of contracting infection. Historically, many common misconceptions have driven HIV-related stigma and discrimination [21]. In this study, nurses’ willingness to care was associated with attitudes of avoiding HIV-infected individuals, as well as prejudices that infected people may have previously engaged in homosexual activity, injectable drug use or have had multiple sex partners. It has been previously reported that moderate levels of HIV knowledge might be insufficient for eliminating nurses’ discriminatory attitudes against those with HIV [22]. Healthcare employers should ensure sufficient HIV education for nurses to facilitate unbiased patient care. Age associations in this study were consistent with previous research [19,23,24], although some investigators found different results attributable to varied social backgrounds [4,5]. One study found younger nurses more willing to care for patients with HCV because of their knowledge and frequent contact with such individuals [19]. Nurses, like anyone, may be influenced by their family members who might consider HIV to represent ‘social evils’ and ask them to reduce contact with infected patients [25,26]. Education on infectious diseases for healthcare workers and communities may improve public perceptions of infected individuals, particularly where cultural beliefs influence such perceptions [27]. This study confirmed a positive relationship between accepting attitudes towards HIV-infected co-workers and subsequent willingness to care for infected patients. This suggests that some nurses consider the human rights of colleagues similar to patients living with HIV. Management of infected healthcare workers using appropriate occupational health systems will be important for not only preventing provider-to-patient transmission, but also for promoting positive attitudes in general [28]. Key points Around 4 in 10 of our sample of Thai nurses were unwilling to care for HIV- or HCV-infected patients. Fear of hepatitis C virus transmission, human immunodeficiency virus-related stigma and discrimination, and age were associated with nurses’ unwillingness to provide care for infected patients. Minimizing the risk of nosocomial transmission and improving the public perception of infected patients may help improve nurses’ willingness to provide care. Funding National Center for Global Health and Medicine, Japan (26-2 and 27-4). Acknowledgement We gratefully acknowledge Mr Amphol Dongnoi for his extensive support in the data collection for this study. Competing interests None declared. References 1. Khuat T , Ashburn K , Pulerwitz J , Ogden J , Nyblade L. 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A consensus for occupational health management of healthcare workers infected with human immunodeficiency virus, hepatitis B virus, and/or hepatitis C virus . J Occup Health 2017 ; 59 : 304 – 308 . Google Scholar CrossRef Search ADS PubMed © The Author(s) 2018. Published by Oxford University Press on behalf of the Society of Occupational Medicine. All rights reserved. For Permissions, please email: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

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Occupational MedicineOxford University Press

Published: Mar 5, 2018

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