Fear of HIV Susceptibility Influencing Burden of Care among Nurses in South-East Nigeria

doi:10.4236/wja.2013.33031

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World Journal of AIDS, 2013, 3, 231-238

http://dx.doi.org/10.4236/wja.2013.33031 Published Online September 2013 (http://www.scirp.org/journal/wja)

231

Fear of HIV Susceptibility Influencing Burden of Care

among Nurses in South-East Nigeria

Ekaete Francis Asuquo1*, Prisca Adejumo2, Josephine Etowa1, Adebayo Adejumo2

1Faculty of Health Sciences, School of Nursing, University of Ottawa, Ottawa, Canada; 2Department of Nursing, University of Iba-

dan, Ibadan, Nigeria.

Email: *[email protected], [email protected]

Received July 11th, 2013; revised August 9th, 2013; accepted August 15th, 2013

License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

HIV/AIDS currently is a major cause of disability and mortality especially in sub-Saharan Africa. As the population

affected by HIV/AIDS increases, so does the burden of this chronic disease and the challenges associated with caring.

HIV scourge in Nigeria has been overwhelming since 1992 with debilitating impacts and this study presents the extent

of fear of susceptibility and the level of caregivers burden among Nigerian nurses. To direct the study, three special

objectives and one hypothesis were raised, which were to determine the extent of fear of susceptibility and perceived

seriousness of HIV, to ascertain the percentage of nurses who tested to know their HIV status and the associated level of

caregivers burden among nurses. The study also determined the relationship between fear of susceptibility and care-

giver’s burden. A purposive sampling technique was used to select 210 nurses caring for people living with HIV/AIDS

in the University of Calabar Teaching Hospital, Nigeria. Structured questionnaires and relevant validated scales such as

Zarit Burden Interview [1] and abridged Champion Health Belief Model Scale [2] were used to elicit data. Results re-

vealed that the majority of 41.0% respondents nursed fear of susceptibility despite the practice of universal precaution

and perceived HIV as a serious and life threatening infection, 36.0% were not sure of their experience and 23% had no

fear of HIV. 33.8% respondents experienced mild to moderate level of burden, 27.2% respondents experienced moder-

ate to severe level of burden while 15.7% experienced severe burden. A Chi Square value of 68.2 at P < 0.05 was ob-

tained showing a significant relationship between fear of susceptibility and caregivers burden. This paper discusses the

implications of these findings for nursing and health care and recommends the implementation of educational opportu-

nities to allay fears and minimize caregiver burden among nurses and other health care professionals.

Keywords: HIV/AIDS Susceptibility; Caregivers’ Burden; Nurses; Nigeria

1. Introduction

HIV/AIDS has become one of the greatest public health

challenges of our time, with about 34 million people glo-

bally living with HIV at the end of 2011 [3]. The burden

of this epidemic varies between the developing and the

developed countries. With sub-Saharan Africa bearing

the brunt and accounting for 69% (22.9 million) of the

people living with HIV worldwide, it implies that 1 in

every 20 adults (4.9%) is affected with HIV [3]. Cross

River State (study site) is in the South region of Nigeria

with an HIV prevalence of 7.1% [4]. This high preva-

lence in Cross River State and Nigeria as a whole has in-

creased the burden on the health care system and pro-

found impact on its human resources with health workers

and their families directly affected and infected by the

HIV virus [5]. In 2006 [6], 48 health workers were in-

fected with HIV by occupational exposure in South Af-

rica and in Malawi, reports of HIV infection among nurs-

es resulted in migration of nurses to other professions [7].

Another report [8] indicates that out of 24,844 adults

with HIV working in health care centers, nurses compris-

ed of 21% of the healthcare personnel with HIV/AIDS.

The fear of susceptibility to HIV through occupation has

created unfavourable attitude among nurses and a con-

stant issue of concern [8,9].

The chronic nature of HIV with mandatory death out-

come produces anxiety, over-safety practices and fears of

occupational contagion among nurses [10,11]. Although

studies have revealed that the occupational risk of HIV is

low [6,12], yet caring for people living with HIV/AIDS

*Corresponding author.

Fear of HIV Susceptibility Influencing Burden of Care among Nurses in South-East Nigeria

232

still produces a high level of physical, social and emotio-

nal consequences among nurses. A significant correlation

has been found to exist between level of burden and tak-

ing up or maintaining caregiver’s role and the higher the

burden level, the lower the quality of care [13]. The fear

of susceptibility or perceived vulnerability infers that an

individual could be susceptible to illness in general [14]

or the risk/probabilities of contracting a health disease

[15]. The perceived susceptibility is associated with per-

ceived severity and perceived threat to life especially when

it is associated with HIV [14,15]. But there are conditio-

nal and unconditional susceptibilities to illnesses [16]

such that even when an individual behaviour does not

promote risk of HIV, occupational contagion becomes an

issue with health workers and nurses in particular, since

they remain in constant contact with their patients in their

line of duty.

The fear of contagion [17] emanates from the surrepti-

tious meaning that people from different cultures attach

to HIV/AIDS, such as mysterious affiliation with death,

or as a form of punishment from sexual promiscuity.

Death is the feared and most objectionable of all human

conditions, therefore if HIV symbolizes death, the fear of

death is projected into the fear of HIV. Also common

with most HIV/AIDS caregivers is the anxiety over safe-

ty practices and occupational susceptibility and these an-

xiety increases their levels of burden [18] and the fear of

physical and social contagion also accompanies nurses’

working day [5]. The fear of susceptibility has become a

major plague that has threatened a caregiving role and

heightened the burden of caregivers sometimes without

basis for such fear [6,12,19-21]. Even family ties have

been affected as family members fear hug and kisses

from those infected with HIV [22]. Reports of unfavour-

able attitude of health workers towards HIV patient indi-

cated that personal behaviour puts health workers at risk

much more than occupational contagion [19,23]. Yet the

need to eliminate these feelings of susceptibility becomes

the panacea that will improve quality of care.

The concept of burden had been acknowledged since

1960 immediately following the report that burden was

associated with caring for mentally ill relatives [24]. Re-

searchers in recent times have conceptualized burden as

two dimensional subjective/objective or a multidimensio-

nal construct with physical, emotional (psychological), so-

cial and financial appraisal of caregiving mostly by fam-

ily caregivers [25,26].

The unique role of nurses among other health care

workers in ameliorating the burden of disease on the

health care system, community and the global society as

a whole has been recognized [27-29]. They are expected

to implement new initiatives and policies without addi-

tional staffing thereby bearing the brunt of an increased

disease burden [5]. With the challenge of HIV, they have

become the battle axe to combat the epidemic and their

activities ranging from caring for people living with HIV/

AIDS (PLWHA) to implementation of policies affiliated

with HIV and measures to reduce HIV to where it is no

longer a public health challenge. Little or no attention is

given to the psychological as well as the social impact

this epidemic has on the life of these caregivers [8,10].

Reports have shown high levels of stress and depression

among the Niger Delta inhabitants of Nigeria, and attrib-

uted to increased anxiety among nurses due to fear of

contagion [9], which is comparable to stress or burnout

of those caring for cancer patient [18]. In Cape Town,

South Africa, HIV had a lot of psychological impact on

nurses which dramatically transformed their working life

to that of stress and anxiety about fear of injury and dis-

closure, and ultimately impacted their family life, with

feelings of hopelessness and guilt [5].

The social, physical, psychological and emotional im-

pact of caring for PLWHA often increased the level of

burden of caregivers and portrays them as targets of

HIV-related prejudice and discrimination [30,31]. The

social impact emanates from the stigma associated with

HIV and caregivers are stigmatized as harbouring the

HIV virus themselves besides caring for the sick [32].

This limits their socializing ability and inability to dis-

close such feeling to others or family members [30].

Case studies indicate that the burden of care increases

with the impairment in functional activities and the dura-

tion of care [13] and a significant correlation exist be-

tween the number of caregiving tasks and caregivers bur-

den [33]. As patients’ dependency on caregivers increas-

es, the level of burden on nurse rises [34].

With increased burden, the nurse may develop feelings

of anger, grief, loneliness, burnt-out and resentment,

which may lead to poor quality of care and ill health of

the nurse. This is typical in caring for patients with AIDS

who may be in the terminal stage of HIV infection. With

typical obnoxious situation of one nurse to thirty in Ni-

geria [35,36] or a ratio of one is to fifty in Malawi [7],

the burden experienced by nurses will be severe. There-

fore, measuring the burden level of nurses in Nigeria and

other sub-Saharan countries with high HIV/AIDS preva-

lence becomes imperative, as a higher level of burden

has a synergistic effect on the wellbeing of those expect-

ed to combat the ravaging effect of HIV epidemic [26].

This study therefore assesses the level of caregivers bur-

den, the extent of fear/feeling of susceptibility and per-

ceived seriousness among nurses.

2. Materials and Methods

2.1. Location of the Study

This study was conducted at the University of Calabar

Teaching Hospital (UCTH), a regional tertiary Hospital

Fear of HIV Susceptibility Influencing Burden of Care among Nurses in South-East Nigeria

233

in Calabar metropolis, Nigeria (Figure 1). This hospital

serves as referral center to other hospitals, health centers

and other health institutions where HIV/AIDS patients

are admitted. The study was informed by the high preva-

lence of HIV/AIDS in Calabar Urban (10.4%) [4].

2.2. Methods

The study participants were nurses working in University

of Calabar Teaching Hospital as at 2010. A purposive

sampling technique was used to obtained data from nurs-

es who were willing to participate in the study. All nurses

who had been involved in care giving of PLWHA for a

period of not less than one month were included in the

study. About 221 nurses who were working in units with

PLWHA responded and 210 completed the questionnair-

es. The study was submitted to the University of Calabar

Teaching Hospital Ethics and Research Committee, who

gave the approval for conducting the study. Informed

consent was obtained from study participants following

full description of the aim and objectives of study.

Data was collected using structured questionnaires,

and relevant validated scales such as Zarit Burden Inter-

view [1] and abridged Champion Health Belief Model

Scale (CHBMS) [2]. The structured questionnaires con-

sisted of 27 items (7 on demographic variable, 10 on fear

of susceptibility and 10 on perceived seriousness). The

CHBMS [2], which was developed for measuring per-

ceived susceptibility to breast cancer, was modified and

used to assess the perceived fear of susceptibility in rela-

tion to HIV/AIDS among nurses. The scale is made up of

30 items with a 3-point Likert rating scale ranging from

strongly disagree to strongly agree. Only 10 questions

relating to perceived susceptibility and perceived seri-

ousness of HIV/AIDS were used. The instrument had a

reliability coefficient ranging from 0.88 to 0.92. The Za-

rit Burden Interview (ZBI) scale was modified to nurses

and was made up of 22 items also, to reflect the emotio-

nal, physical health and social impact of care giving on

nurses while caring for PLWHA. The respondents indi-

cated the discomfort they experienced of particular items

on a 5-point Likert scale ranging from 0 - 4. The total

score ranged from 0 to 88 and a high score correlated

with higher level of burden. The Psychometric properties

of Zarit Burden Interview scale had been examined in

many studies with an estimated internal consistency reli-

ability of Chronbach’s alpha range of 0.88 to 0.92 [25].

The instruments were pilot-tested on 20 nurses in Gen-

eral Hospital, Calabar. This was done to gain experience,

applicability of the instrument to our environment and

assess the understanding of the questions and as a result,

modifications were made on some of the items to reflect

nursing perspectives.

2.3. Data Analysis

The data collected were analysed using the Statistical

Package for the Social Sciences (SPSS 16.0) software to

generate the means and percentages of the values. By the

application of inferential statistics (Chi-Square test), the

Figure 1. Map of Nigeria showing the location of Calabar, the study area.

Fear of HIV Susceptibility Influencing Burden of Care among Nurses in South-East Nigeria

234

level of significance was also determined at the P-value

of 0.05. The Zarit interview scale had a reliability coeffi-

cient ranging from 0.88 to 0.92. For level of burden,

scores ranged from 0 to 88. Zero to twenty (0 - 20)

represents little or no burden, 21 - 40, mild to moderate

burden; 41 - 60, moderate to severe burden and 61 - 88,

severe burden [37]. The Champion Health Belief Model

Scale (CHBMS) measuring approach of fear of suscepti-

bility and percentages were used to grade those who have

perceived susceptibility to HIV through caring.

3. Results

3.1. Socio-Demographic Characteristics of

Respondents

A total of 221 nurses participated in the study (Table 1).

Data from 210 participants were completely filled and

Table 1. Socio-demographic characteristics of respondents

of study participants in Nigeria.

Characteristics of respondents Number %

Male 2 0.95

Female 208 99.05

Age (in years)

21 - 31 42 20

31 - 40 38 18.1

41 - 50 83 39.5

51 years and above 47 22.4

Religion

Christianity 210 100.0

Marital Status

Married 139 66.2

Single 36 17.1

Divorcee 31 14.8

Separated 4 1.9

Occupational

status 32 15.2

NO 1 30 14.3

NO 2 25 11.9

SNO 60 28.6

PNO 43 20.5

ACNO 20 9.5

CNO 25 11.9

Professional 150 71.4

Qualification 39 18.6

RN/RM 21 10.0

BNSC

MSc

analysed while 11 were discarded since their question-

naires were not completely filled. The majority 208 (99%)

respondents were female, 83 (39.5%) in the age range of

41 - 50 years. All were Christians by religion, and about

66% (139 respondents) were married, while 18.6% (39

respondents) had a first degree (BNSc) and above.

Nursing care giving role involves daily and close as-

sociation of the nurse care giver with patient as long as

she is on duty. From this study, 86 (41.0%) respondents

strongly agree that they experience fear of susceptibility,

77 (36.7%) respondents neither agree nor disagree to fear

of susceptibility, while 47 (22.3%) respondents did ex-

perience fear of susceptibility (Ta ble 2 ). The majority 72

(34.3%) perceived HIV as a serious and life threatening

infection, 71 (33.8%) respondents neither agree nor dis-

agree to seriousness of HIV while 67 (31.9%) perceived

it as not being life threatening (Table 3).

Among the 210 respondents who participated in the

study, about 182 (86.2%) respondents never tested to

know their HIV status while 28 (13.8%) had determined

their HIV status (Figure 2).

The relationship between fear of susceptibility and

care givers burden was significant among the respon-

dents (X2 = 68.2 at P < 0.05, n = 210), Tables 4 and 5.

Out of 210, 47 respondents expressed no fear of suscep-

tibility, 15 expressed they had burden of care while 32

had no burden. Seventy seven respondents were uncer-

tain if they experienced fear of susceptibility or not, 67

experienced care givers burden and 10 respondents did

not. Of about 86 respondents with fear of susceptibility, 7

had no burden while 79 experienced burden. A Chi

Square value of 68.2 at P < 0.05 was obtained showing a

significant relationship between fear of susceptibility and

care givers burden. This indicates that the more the fear

of susceptibility, the higher the care givers burden among

the nurses and the lower the nursing services rendered to

PLWHA.

13.8%

86.2%

Not T ested

Tested

Figure 2. Pie chart showing the number of respondents who

have undergone HIV testing.

Fear of HIV Susceptibility Influencing Burden of Care among Nurses in South-East Nigeria 235

Table 2. Fear and feeling of susceptibility among nurses caring for PLWHA in Nigeria.

Question (N = 210) Strongly

Disagree/Disagree Neither Agree/Nor

Disagree Strongly

Agree/Agree

Susceptibility N % N % N %

It is extremely likely I may contact HIV/AIDS

in the future through my occupation 62 29.5 99 47.2 49 23.3

I feel I may contact HIV/AIDS in the future through my occupation 38 18.1 77 36.7 95 45.2

There is a good possibility I may contact HIV/AIDS in the next 10 years 54 25.7 86 41 70 33.3

My chances of contracting HIV/AIDS through my occupation are great 23 11 41 19.5 146 69.5

I am more likely than the average nurse to contact

HIV/AIDS through my occupation 59 28.1 82 39 69 32.9

If I am HIV/AIDS positive, I would not live longer than 5 years 99 48.6 74 34.8 37 17.6

Total susceptibility score for all respondents 47 22.3 77 36.7 86 41

Table 3. Perceived Seriousness among nurses caring for PLWHAs in Nigeria.

Question (N = 210) Strongly

Disagree/Disagree Neither Agree/Nor

Disagree Strongly

Agree/Agree

Seriousness N % N % N %

I am afraid to think about HIV/AIDS 25 11.9 71 33.8 114 54.3

Problems I would experience with HIV/AIDS would last a long time. 62 29.5 102 48.6 46 21.9

HIV/AIDS would threaten a relationship with

my boyfriend, husband or partner 55 26.2 39 18.6 116 55.2

If I had HIV/AIDS my whole life would change 95 45.2 69 32.9 46 21.9

Total seriousness score for all respondents 67 31.9 71 33.8 72 34.3

4. Discussion

The changing demographics in developing countries with

“Youth bulge” (majority in population between the age

of 15 and 30 years) have resulted in an increasing num-

ber of births in this sexually active age group [38]. Pre-

vious report [4] reveals that this age group is the worst

hit with HIV/AIDS, which in turn will increase the bur-

den of those caring for them but an improved technology

and medical care could lead to improvement in life ex-

pectancy [38]. This improvement in turn results in an in-

crease burden to care givers. These improvements in te-

chnology have also made patients to survive longer and

continue treatment for a longer period of time. Even

though this improvement is welcomed, it has also created

major challenges for health care professionals especially

the providers of curative and palliative cares who deliver

emotional and practical support to patients living with

terminal [39]. As population affected by HIV/AIDS in-

creases, the burden of this chronic disease also grows. As

treatment options have expanded, so have the stresses

experienced by caregivers. Complementary to the stress-

es of caregiving is the associated fear of susceptibility

especially in the presence HIV pandemic which has com-

pounded care giving role.

Nurses, as professional care givers are well aware of

the mode of transmission of HIV, but the fear of suscep-

tibility as observed during this study was generally high

among the formal care givers. In spite of the practice of

universal precaution in the hospitals, minor injuries

which are realized after removing gloves, and accidental

tear of gloves also do occur. With constant care to

PLWHA in their terminal stages, the fear of susceptibil-

ity through caring increases among these caregivers.

These findings are similar to previous reports that some

care givers are burdened by the fear of contracting HIV

even when they know there is little or no basis for such

concerns [6,12,19-22]. From a recent study [17], HIV is

viewed as an affiliate of death, and as a form of punish-

ment for sexual promiscuity. Therefore, it is not surpris-

ing to observe that most respondents in this study per-

ceived HIV as a serious threat to life and their relation-

ships, and are afraid to think about HIV/AIDS. These per-

ceived seriousness influences their caregiving relation-

ship to PLWHA. It has been revealed that perceived

Fear of HIV Susceptibility Influencing Burden of Care among Nurses in South-East Nigeria

236

Table 4. The distribution of caregivers burden on Zarit

Burden Interview scale (ZBI).

Level of Burdens N = 210 % Range

No burden 49 23.3 0 - 21

Mild to moderate burden 71 33.8 21 - 40

Moderate to severe 57 27.2 41 - 60

Severe burden 33 15.7 61 - 88

Total 210 100 88

Table 5. The relationship between fear of susceptibility and

care givers burden among study participants.

Fear of Susceptibility Burden Total

No Burden Burden

No fear of susceptibility 32 (11.0) 15 (36.0)47

Not sure of experience 10 (18.0) 67 (59.0)77

Perceived fear of susceptibility 7 (20.1) 79 (65.9)86

Total 49 161 210

Values in parentheses are expected frequencies; (Χ2 = 68.2 at P < 0.05, DF 2,

n = 210).

susceptibility is associated with supposed severity and

threat to life especially when associated with HIV [14,

15]. But amazingly, with the associated fear, most nurses

refuse to undergo HIV test (Figure 2) and do not report

about their feeling of susceptibility. This may be due to

the psychological impact associated with HIV positivity

which many health workers refuse to disclose such feel-

ings to others or family members [30]. Culturally in

Cross River State, Nigeria, it is believed that an individ-

ual is not tormented by what is not known, but knowl-

edge about one’s positivity arouses the emotional trauma

and concerned persons start counting their days to the

grave.

In this study, the significant relationship observed be-

tween fear of susceptibility and care givers burden (Ta-

ble 4, Χ2 = 68.2 at P < 0.05, DF 2, n = 210) suggests that

the fear of susceptibility has a remarkable impact on the

burden experienced by care givers. This may be associ-

ated with the fact that caregivers may dislike any care

that brings them in close proximity with PLWHA as

every contact may imply potential risk to HIV, therefore

every move is threaded with caution. Most PLWHA es-

pecially at the terminal stage may lack many functional

abilities and almost all activities of daily living are assis-

ted or performed by the nurse. With a high fear of sus-

ceptibility, the nurse may be reluctant to respond to the

nursing care routines of PLWHA as the need arises. This

situation is worsened with the poor staffing condition of

our hospitals that does not meet the World Health Or-

ganisation standard of nurse patient-ratio [36], hence bur-

den increased as workload increases.

These findings are comparable to previous reports [13,

33,34] where correlations were found between functional

abilities of care receivers, care giving task, duration of

care and the level of burden experienced by care givers

respectively.

This therefore implies that as patients dependency on

caregivers increases, the fear of contagion rises and nurs-

es may develop feelings of burnout [8,9]. Such increased

workload may lead to immigration of nurses to develop-

ed countries and to other professions [7,18]. The need to

eliminate fear of susceptibility and reduce the burden ex-

perienced cannot be overemphasised, because reduced

burden correlates with high quality of care and caregivers

must function optimally (emotional, physical and social

well being) in order to provide care receiver with the ex-

pected high quality care.

5. Conclusion/Recommendation

The ability to provide quality nursing care requires care-

givers that are endowed with professional skills that

overwhelm the feelings of fear of susceptibility during

nursing practice. HIV infers death to many irrespective

of retroviral drugs used and nurses are well aware of the

seriousness of this deathly disease. Therefore, the level

of burden of nurses caring for PLWHA increases due to

fear of susceptibility. Increasing the number of nurses em-

ployed will also reduce their workload and lessen the le-

vel of burden.

Apart from the above, adopting a holistic approach

towards reducing the fear of susceptibility among nurses

must be encouraged through regular organization of con-

tinuing education programs, workshops and scientific

conferences. Other educational resource avenues such as

in-house seminars shall facilitate exchange of views, ideas

and experiences between support groups, professional

colleagues and caregivers which will ultimately reduce

fear of susceptibility. Nurses should be encouraged to

come together through such fora to share feelings and

experiences, thereby learning from each other for a better

appreciation of nursing a caregiving role. This process

will enhance quality care and subsequent coping abilities

of those caring for PLWHA.

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