ORIGINAL RESEARCH | https://doi.org/10.5005/jp-journals-10015-1919 |
Knowledge, Attitudes and Practices about HIV: A Pilot Study among Tunisian Dentists
1University of Monastir, Faculty of Pharmacy, Laboratory of Medical and Molecular Parasitology-Mycology, LR12ES08, 5019, Monastir, Tunisia; Unit of Oral Microbiology, Faculty of Dental Medicine, University of Monastir, Tunisia
2University of Monastir, Faculty of Dental Medicine, Oral Health and Oro-Facial Rehabilitation Laboratory LR12ES11, 5019, Monastir, Tunisia; Department of Periodontology, University of Dental Clinic of Monastir, Monastir, Tunisia
3Department of Oral Medicine and Oral Surgery, University of Dental Clinic of Monastir, Monastir, Tunisia
4Department of Epidemiology and Preventive Medicine, Fattouma Bourguiba Hospital Teaching Center, Monastir, Tunisia
Corresponding Author: Amira Besbes, University of Monastir, Faculty of Pharmacy, Laboratory of Medical and Molecular Parasitology-Mycology, LR12ES08, 5019, Monastir, Tunisia; Unit of Oral Microbiology, Faculty of Dental Medicine, University of Monastir, Tunisia, Phone: +21696425691, e-mail: besbesemira@gmail.com
ABSTRACT
Aim and objective: The objective of this study was to evaluate knowledge, attitudes, and practices of Tunisian dentists about HIV/AIDS.
Materials and methods: This cross-sectional pilot study was carried out on Tunisian dentists using an online survey. The questionnaire included 34 questions investigating knowledge, attitudes, and practices of the participants. Knowledge attitudes and practices were assessed according to three different scales.
Results: A total of 234 dentists participated in the study. This study showed that 33% of the respondents demonstrated sufficient level of knowledge and 36% of them demonstrated good level. About 90% of them showed excellent practices. In addition, 54% of the participants had neutral attitudes and 42% had positive attitudes towards people living with HIV/AIDS. A significant negative correlation between age and knowledge score was found (p = 0.001). A significant association between knowledge score and the period experience less than 5 years (p = 0.022) was found.
Conclusion: Tunisian dentists had good knowledge and adequate practices about HIV. About a half of the participants expressed hesitation in treating patients with HIV/AIDS. Dental and therapeutic continued education programs are needed to improve their attitudes.
Clinical significance: Good knowledge, attitudes, and practices about HIV in the dental setting allows to ensure an adequate dental care for people living with HIV/AIDS and to enhance infection control and safety for both patients and dental staff.
How to cite this article: Besbes A, Nasri W, Nafti R, et al. Knowledge, Attitudes and Practices about HIV: A Pilot Study among Tunisian Dentists. World J Dent 2022;13(2):155-160.
Source of support: Nil
Conflict of interest: None
Keywords: Attitudes, Dentists, HIV, Knowledge, Practices, Questionnaire
INTRODUCTION
Therapeutic procedures in dentistry frequently involve blood and saliva that may contain a variety of blood-borne pathogens and microorganisms such as HIV, hepatitis viruses, and the possibility of infection during dental care is not uncommon. According to World Health Organization (WHO), there was 4,500 people living with HIV/AIDS (PLWHA) in Tunisia in 2020. Although the prevalence is considered low (less than 0.1), the number of PLWHA is increasing rapidly. Dentists may play a role in the infection’s prevention and treatment. They should not refuse to treat a patient solely based on their HIV-positive status.1
They should have an adequate knowledge about this disease, its oral manifestations, the routes of transmission and the basic principles of prevention in order to ensure his safety and that of his staff and patients. Knowing the HIV status of a patient allow the dentists to provide more comprehensive care as HIV significantly impacts on oral health.2 They also should hold positive attitudes and practices and provide adapted dental care to PLWHA without discrimination or stigmatization. This will contribute to improve the life quality of these patients and prevent the disease spread.
Despite of the professional and ethical responsibility,3 discrimination, and stigmatization among healthcare workers exist and some dentists may be hesitant to treat HIV patients for many reasons. Unwillingness to treat PLWHA has been associated with inadequate knowledge of disease process, transmission, diagnosis, and treatment of these patients.1
To the finest knowledge of the authors, data about dentists’ knowledge, attitudes, and practices about HIV infection are not available in our country. This study aimed to describe knowledge, attitudes, and practices of Tunisian dentists toward PLWHA.
MATERIALS AND METHODS
A cross-sectional pilot study was conducted in the period between July and August 2020, among registered dentists. Data were collected using an online auto-administrated questionnaire. We considered the participation of dentists as an informed consent. Participants also confirmed that all provided data related to the questionnaire were authentic and honest. This latter included a statement assuring the participants that their personal information will not be collected. Ethical clearance was obtained. The questionnaire was adapted from the relevant literature with modifications.3,4,5,6,9 It has been inspired from validated published questionnaires. Since Tunisian dentists speak English and had English courses in their dental academic cursus, we have used the English language without any translation. Several professors have checked out the present questionnaire. It included socio-demographic details and three3 parts: knowledge (17 questions), attitudes (7 questions), and practices (10 questions). Score of knowledge was established by attributing one point to each correct answer. A dentist’s total score can range from 0 (minimum) to 17 (maximum). Knowledge was qualified as poor, sufficient, good, very good, or excellent if the dentist obtained, respectively: less than 8.5 points, between 8.5 and 10.5 points, between 10.5 and 12.5 points or more than 14.5 points. The 4-point Likert scale was used to assess attitudes. The scale ranged from “strongly disagree” with minimum score and “strongly agree” with maximum score,1,2,3,4 or conversely, according to the item’s meaning. The maximum of score that can be obtained was 28 points and the minimum was 7 points.
Attitudes were qualified as: negative attitudes, if the total points obtained was less than 14 points; neutral attitudes, if the total number was between 14 and 21 points or professional attitudes, if the total number was more than 21 points. The 4-point Likert scale (always, often, sometimes, never) was used to express the frequency of respecting the ten hygiene and asepsis rules. Practices were classified as: inadequate (10-20 points); adequate (21-30 points), or excellent, (31 and 40 points). The statistical analysis was carried out with the IBM Statistical Package for the Social Sciences software version 21 (trial version), using the Chi-square test, Student test, ANOVA test and correlation of Pearson test. The scores were expressed in mean ± standard deviation. The validity of the questionnaire was assessed by two professors and an epidemiologist. The reliability was determined by Cronbach alpha. Statistical significance was set at p = 0.05.
RESULTS
A total number of 234 dentists participated to the survey, 79% of them were female. The mean age was 32 ± 7 years. Cronbach alpha test was determined to be 0.87 (high).
This study showed that 71% of the participants were working in the private sector, 16% in the public sector, and 13.5% in the university hospital sector. About 61% of them had less than 5 years of experience, 21.8% between 5 and 10 years, and 17.5% of them had more than 10 years.
More than 98% of respondents thought that a needle stick injury can transmit HIV virus and that drug addicted, sex workers have a high risk of contamination. More than a half thought that saliva cannot be a vector for HIV transmission and more than one third of dentists considered that aerosols from handpieces can be a vehicle for transmission of HIV. About 60% stated that HIV cannot be clinically diagnosed. More than 75% of them thought that hepatitis B control methods provide protection against HIV transmission (Fig. 1).
Fig. 1: Percentage of correct responses to knowledge statements
The present study showed that, 83.3% correctly identified major aphthosis as an oral manifestation of HIV. Only 34.6% of respondents identified correctly hairy leucoplakia as an oral manifestation of HIV (Fig. 2).
Fig. 2: Dentists’ knowledge about oral manifestations of HIV/AIDS before antiretroviral therapy
Overall, 87% of the participants had sufficient to excellent knowledge about HIV/AIDS (Fig. 3).
Fig. 3: Distribution of the dentists by total knowledge score
The mean score of correct answers was 10.66 ± 2.031 out of 17. The average rate of correct answers was 60.78%.
The present study showed that 54% of the dentists had neutral attitudes toward PLWHA and 42% of them had professional attitudes. The mean score of attitudes was 19.7 ± 3 out of 28. Less than a half of the participants strongly agreed that it is their moral responsibility to treat patients with HIV; 46.2% agreed that their knowledge about infection control is enough to treat HIV/AIDS patients. About 47.5 % of them strongly disagreed that if their patient has HIV infection, they will end treating him (Fig. 4).
Fig. 4: Attitudes toward HIV/AIDS patients
The study showed that 98.7% of respondents used to change gloves after use, 87.2% of them washed their hand after each patient, 33.8% never used the rubber dam (Fig. 5).
Fig. 5: Practices toward HIV/AIDS patients
Ninety percent of the dentists had excellent practices toward PLWHA, the rest had good ones. The mean score of practices was 33.4 ± 3 out of 40.
In this study, there was not any difference of the scores of knowledge, attitudes, and practices according to gender. A statistical negative correlation between age and score of knowledge was found (p = 0.001) but no significant correlation with the other scores. Moreover, high levels of knowledge were associated to work experience less than 5 years (p = 0.022) (Table 1).
| Period of Experience | Knowledge Score (Mean ± SD) | p |
|---|---|---|
| <5 years | 11 ± 2 | 0.022 |
| Between 5 and 10 years | 10 ± 2 | NS |
| >10 years | 10 ± 2 | NS |
NS: Nonsignificant
Positive attitudes were associated to the private practicing dentists (0.003) and the university hospitals’ dentists (p = 0.006). There was a low positive significant correlation between score of attitudes and score of practices (p = 0.012). However, no significant association was found between knowledge’ and attitudes scores or knowledge and practices.
DISCUSSION
This pilot study carried out among Tunisian dentists allowed to describe their knowledge level, attitudes and practices toward PLWHA.
Knowledge level of the respondents was very satisfactory. The average percentage of correct answers was 60.78%. This result is similar to the results obtained by Alwafi H et al., who reported an average percentage of correct answers of 59.3% for Saudi Arabian dentists.7
Overall, higher level of knowledge was associated to work experience less than 5 years and to the youngest age. It means that the younger are the dentists, the better is the score. This can be explained by the fact that young dentists are more motivated to look for news about viruses such as HIV. Additionally, their academic courses in virology are more recent. This may also reflect the quality of their academic courses. In fact, majority of Tunisian dentists had their diplomas from the dental faculty which is the only dental faculty in the country. Dental students received curses of virology, hygiene, preventive medicine, and oral medicine from the third year.
In this study, a negative correlation between age and score of knowledge was found. This finding is in consistency with an Iranian study conducted in 2012.5
According to this study, 59% of the dentists declared that PLWHA cannot be clinically diagnosed and 65.4% of them stated that western blot is a diagnostic test these statements are correct. Even that some manifestations may rise suspicion of the infection, serology is mandatory and the technique of western blot is considered the gold standard for diagnosis confirmation.10
Ninety-nine percent of dentists affirmed that needle stick injury can transmit HIV virus. This finding is correct. A needle stick is the most common risk of disease transmission in the dental setting. There is a 0.3-0.03% chance of HIV infection due to needle injury.11 Even if it does not lead to the transmission of disease, the incidence of needle sticks among healthcare workers is worryingly frequent.12 This can be explained by the frequent use of small-bore needles 13 that should be placed in adequate containers. Only 37.6% of respondents affirmed that aerosols from handpieces can be a vehicle for HIV transmission, this statement had the lowest correct answer and this may be due to the fact that reports of HIV transmission through this route are rare, but the possibility does exist.14 Just over than a half of the dentists answered correctly that saliva cannot be a vector for HIV transmission.
It is comforting to note that there is no reported case of patient-to-dentist transmission of HIV by contact with saliva alone 15 unless it is mixed with patient’s blood where the risk is increasing. This is can be explained by the low concentration of HIV in saliva and other body fluids (tears, urine). Then, the transmission through these fluids is considered negligible.16
Most of the participants had good knowledge about HIV/AIDS risk groups. They correctly identified that drug-addicted and sex workers are in the highest risk groups.
In the current study, the majority of the dentist declared that hepatitis B control methods provide protection against HIV transmission. HBV and HIV have common routes of transmission and endemic areas, but HBV is potentially 100 times more infectious than HIV.17
With regard to oral manifestations, knowledge level was satisfying. Although several studies results presented better results.2,3,4,18,19
It is important for dentists to be aware of cancers, metastases, and opportunistic infections’ occurrence in the last stage of HIV infection on PLWHA who are not diagnosticated or treated. Dentists may play an important role in the screening of the disease through examination of these oral manifestations. In this questionnaire, several types of neoplasms in relation with AIDS, which can occur or present metastases in the oral cavity were not stated in the section of oral manifestations. Furthermore, oral manifestations that might appear after retroviral antitherapy were not investigated.
A good knowledge about HIV allowed to dedramatize the disease and overall attitudes were relatively positive. This finding is consistent with the literature.6,8,20,21,22
Only 4% of the participants held negative attitudes toward PLWHA. These attitudes can be attributed to the fear of HIV transmission during dental procedures, lack of clinical skills to provide adequate treatment and safety,1 as well as burnout or cultural background where people judge sexual relationships, prostitution, and homosexuality. All these factors can lead to hesitation and unwillingness to provide care.
Our result was more satisfying than several studies which showed negative attitudes.5,7,23,24
The adequate attitudes were significantly associated with university hospital group. This can be explained by the fact that patients have more confidence in the academic doctors. They often believe that academic doctors are more skilled to provide them a better dental care. Academic doctors can be more comprehensive because they are more likely to be in contact with them. In this context, dentists who are working in the academic hospitals should act as a role model for all dental students regarding the dental treatment of PLWHA.1
With respect to fear of contagion and negative emotions, half of the participants disagreed or strongly disagreed that if their patient has HIV infection, they will end treating him. Forty percent of the participants disagreed that they preferred not to treat PLWHA and 14.1% disagreed that they worry about being infected with HIV by their patients. These findings are lower in comparison to the study of Jahan M et al. where the response rate to the same statement “I worry about being infected with HIV by my patients” was 42.9%.25 According to Neenu, fear of contagion was the most common barrier which arrest doctors from treating HIV-infected patients.26 It can also be explained by anxiety and fear of being legally pursued or judged if a dentist contaminates his patients or staff.
Regarding ethics and legal obligations, 45% strongly agreed that they are morally responsible to treat HIV/AIDS patients. Nevertheless, less than a half of the dentists (43.8%) thought that their knowledge is not enough to allow them to treat this population. This finding highlighted the necessity to enrich our dental and medical academic programs and courses about hygiene and prevention. In this case, continued education in this field is required in order to deepen their knowledge and make them more confident when they are faced to PLWHA or any other infection in dental setting.
The present study showed that 45.3% had good attitudes because they disagreed that blood test should be taken for diagnosis of HIV infection in all dental patients.
Majority of participants disagreed that dentists with HIV/AIDS should not be allowed to practice. On one hand, it is relieving that dentists did not show discrimination between them, on other hand it reflects the good level of knowledge about the transmission routes in the dental setting.
Practices were investigated on whether dentists are compliant to the hygiene and asepsis rules. The study showed that the majority of the recommendations were respected notably wearing disposable gloves, washing hands between patients, wearing the masks. These measures allow to avoid cross-contamination.
Over all, practices were excellent and dentists were respecting the hygiene and asepsis measures. Here, we should also mention that this survey was distributed in the period of pandemic due to SARS-CoV-2 where dentists were worried about this infection. Consequently, their efforts to tackle the epidemic had positive effects on other eventual infection in dental settings. Nonetheless, it was disappointing that only 11.5% used the rubber dam regularly and 33.8% never used it. This may be due to the unavailability of this equipment in the country in relation with importation difficulties.
The statistical analysis did not indicate any significant association between knowledge’ and attitudes scores or between knowledge and practices. However, a low positive significant correlation between score of attitudes and score of practices was found. This result is in accordance with the study of Khosravanifard B et al. who indicated that although knowledge is important to improve attitudes, it may not be sufficient.5
This study provided an overview of knowledge, attitudes, and practices Tunisian dentists about HIV. However, it had some limits. As it was a pilot study with a small sample size, further studies with larger sample should be carried out to investigate these KAP of dentists. Authors are encouraged to calculate the sample size. Also, as for any self-administrated questionnaire, participants responses may not reflect their real attitudes or practices. They may find the right answers from anywhere or give socially desirable responses. Subsequently, negative behaviors may be underestimated. Practices should better be evaluated using direct observation. In addition, the length of the questionnaire may discourage participants to answer with precision. Thus, we suggest to validate a brief standardized questionnaire that would be more adapted to the Tunisian environment.
CONCLUSION
Dentists displayed good level of knowledge particularly with regard to the HIV risk groups, infection control and prevention. Good knowledge was translated into adequate practices. Dentists recently qualified had the best knowledge toward PLWHA. Even though, dentists expressed their desire to benefit from continued education of hygiene and prevention in the dental setting.
Attitudes were mixed between professionalism and neutral opinions and some dentists expressed reluctance in treating PLWHA. Changing the attitudes among dentists and health workers remains crucial for the success of Tunisia’s HIV/AIDS response.
CLINICAL SIGNIFICANCE
Good knowledge, attitudes, and practices about HIV in the dental setting allows to ensure an adequate dental care for people living with HIV/AIDS and to enhance infection control and safety for both patients and dental staff.
ACKNOWLEDGMENTS
The authors are grateful to all the study participants.
REFERENCES
1. Dhanya RS Hegde V Anila Set al. Knowledge, attitude, and practice towards HIV patients among dentists. J Int Soc Prev Community Dent 2017;7(02):148-153. DOI: 10.4103/jispcd.JISPCD_57_17
2. Aggarwal A Panat SR. Knowledge, attitude, and behavior in managing patients with HIV/AIDS among a group of Indian dental students. J Dent Educ 2013;77(09):1209-1217. DOI: 10.1002/j.0022-0337.2013.77.9.tb05594.x
3. Prabhu A Rao AP Reddy Vet al. HIV/AIDS knowledge and its implications on dentists. J Nat Sci Biol Med 2014;5(02):303-307. DOI: 10.4103/0976-9668.136171
4. Ellepola ANB Sundaram DB Jayathilake Set al. Knowledge and attitudes about HIV/AIDS of dental students from Kuwait and Sri Lanka. J Dent Educ 2011;75(04):574-581. DOI: 10.1002/j.0022-0337.2011.75.4.tb05082.x
5. Khosravanifard B Rakhshan V Ghasemi Met al. Tehran dentists’ self-reported knowledge and attitudes towards HIV/AIDS and observed willingness to treat simulated HIV-positive patients. Easter Mediterr Health J 2012;18(09):928-934. DOI: 10.26719/2012.18.9.928
6. Singh VP Osman IS Rahmat NAet al. Knowledge and attitude of dental students towards HIV/AIDS Patients in Melaka, Malaysia. Malays J Med Sci 2017;24(03):73-82. DOI: 10.21315/mjms2017.24.3.9
7. Alwafi HA Meer AMT Shabkah Aet al. Knowledge and attitudes toward HIV/AIDS among the general population of Jeddah, Saudi Arabia. J Infect Public Health 2018;11(01):80-84. DOI: 10.1016/j.jiph.2017.04.005
8. Rostamzadeh M Afkhamzadeh A Afrooz Set al. Dentists’ knowledge, attitudes and practices regarding Hepatitis B and C and HIV/AIDS in Sanandaj, Iran. BMC Oral Health 2018;18:220. DOI: 10.1186/s12903-018-0685-1
9. Gunardi I Salsabila Nurina N Marcia nullet al. Dentists experience influences knowledge and attitudes toward HIV patients in West Jakarta, Indonesia, and validation of a new questionnaire. Oral Dis 2020;26Suppl 1:127-132. DOI: 10.1111/odi.13393
10. Tavakoli A Karbalaie Niya MH Keshavarz Met al. Current diagnostic methods for HIV. Future Virol 2017;12(03):141-155. DOI: 10.2217/fvl-2016-9999
11. Wyżgowski P Rosiek A Grzela Tet al. Occupational HIV risk for health care workers: risk factor and the risk of infection in the course of professional activities. Ther Clin Risk Manag 2016;12:989-994. DOI: 10.2147/TCRM.S104942
12. Wilburn SQ Eijkemans G. Preventing needlestick injuries among healthcare workers: a WHO-ICN collaboration. Int J Occup Environ Health 2004;10(04):451-456. DOI: 10.1179/oeh.2004.10.4.451
13. McCarthy GM Ssali CS Bednarsh Het al. Transmission of HIV in the dental clinic and elsewhere. Oral Dis 2002;8Suppl 2:126-135. DOI: 10.1034/j.1601-0825.8.s2.3.x
14. Al-Naimi R Knowledge G. Attitude and health behavior of dental students towards HIV patients. Al-Rafidain DentJ 2009;9:110-119. DOI: 10.33899/rden.2009.8991
15. Serb P Yeung S. HIV infection and the dentist. 1. The presence of HIV in saliva and its implications to dental practice. Aust Dent J 1994;39(02):67-72. DOI: 10.1111/j.1834-7819.1994.tb01375.x
16. Page-Shafer K Sweet S Kassaye Set al. (C2) Saliva, breast milk, and mucosal fluids in HIV transmission. Adv Dent Res 2006;19(01):152-157. DOI: 10.1177/154407370601900127
17. Khan F, Shams S, Qureshi ID, et al. Hepatitis B virus infection among different sex and age groups in Pakistani Punjab. Virol J 2011;8(1):225. DOI: 10.1186/1743-422X-8-225
18. Sadeghi M Hakimi H. Iranian dental students’ knowledge of and attitudes towards HIV/AIDS patients. J Dent Educ 2009;73(06):740-745. DOI: 10.1002/j.0022-0337.2009.73.6.tb04753.x
19. Li R Dong W He Wet al. Chinese dental students’ knowledge and attitudes toward HIV/AIDS. J Dent Sci 2016;11(01):72-78. DOI: 10.1016/j.jds.2015.09.001
20. Park J-C Choi S-H Kim Y-Tet al. Knowledge and attitudes of Korean dentists towards human immunodeficiency virus/acquired immune deficiency syndrome. J Periodontal Implant Sci 2011;41(01):3-9. DOI: 10.5051/jpis.2011.41.1.3
21. Gemeda T Gandile A Bikamo D. HIV/AIDS Knowledge, attitude and practice among Dilla University Students, Ethiopia. Afr J Reprod Health 2017;21:49-61. DOI: 10.29063/ajrh2017/v21i3.4
22. Labra O Lacasse A Gingras-Lacroix G. Attitudes et connaissances d’étudiants universitaires à l’égard du VIH-sida2018;63(02):1-20. DOI: 10.7202/1046496ar
23. El-Maaytah M Al Kayed A Al Qudah Met al. Willingness of dentists in Jordan to treat HIV-infected patients. Oral Dis 2005;11(05):318-322. DOI: 10.1111/j.1601-0825.2005.01126.x
24. Lee C Fan Y Starr JRet al. Dentists’ and dental students’ attitudes, knowledge, preparedness, and willingness related to treatment of people living with HIV/AIDS in China. J Public Health Dent 2017;77(01):30-38. DOI: 10.1111/jphd.12168
25. Jahan MS Shaikh MH Begum Jet al. Knowledge about HIV/AIDS among the dental students in Dhaka. Update Dental College Journal 2012;2(02):23-27. DOI: 10.3329/updcj.v2i2.15531
26. Neenu E Sharma V Bhat PKet al. Barriers in providing dental treatment to HIV/AIDS patients. Int J Contemp Med 2017;4(06):1402-1405. ISSN (Online): 2393-915X.
________________________
© The Author(s). 2022 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and non-commercial reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.