Comparison of perceptions of HIV/AIDS between Cameroonian, Honduran and American nursing students after Peerled Education

The study examined changes in HIV/AIDS-related knowledge, attitudes, and beliefs between cohorts of Cameroonian, Honduran, and American nursing students across iterations of a train-the-trainer program.


Introduction and Background
The global HIV pandemic continues to be a global challenge as we face at least 35 million persons infected with HIV worldwide [1]. Worldwide for fear of acquiring the disease [3]. Signifi cant percentages of nurses, ranging from 8% to 26%, stated that they had the right to decline providing care to patients with HIV/AIDS [4,5]. These negative attitudes towards patients with HIV/AIDS were identifi ed in all the countries examined including Nigeria [6], Australia [7], Russia [3], and the US [8]. One of the causes for US and Indian nurses' reluctance to care and negative attitudes toward people with HIV/AIDS was recognized as a lack of education [8,9].
HIV-stigma is a major reason why HIV continues to be a global epidemic. Interventions targeting HIV-stigma are therefore necessary [10]. Not only is stigma a global problem, but the inaccurate information about HIV/AIDS adds to that level of stigma. While the US has many laws to prevent discrimination, many global countries do not. We know that when society has a negative view of people living with HIV, this is often from a lack of understanding and fear of the unknown. That lack of knowledge will lead to continuing judgment of others and placing moral values onto others due to misunderstanding [11]. Education may be better in the US, but there still is a great deal of stigma here and abroad.
The knowledge and attitudes of nursing students towards persons living with HIV/AIDS have often been of concern for after Peer-led Education. Arch Nurs Pract Care 3(1): 057-063. DOI: http://dx.doi.org/10.17352/anpc.000027 both nursing faculty and persons receiving care. Previous studies [2,9,12,13] demonstrated that nursing students were hesitant to provide care for fear of "getting the disease".
The Nations AIDS taskforce that the reluctance to care for persons living with HIV/AIDS results in poorer quality of care [14]. Creating learning experiences to prepare students for their professional nursing career in a diverse and global society is increasingly important. Incorporating global nursing experiences into nursing programs is in part based on population trends in the US, as well the demonstrated role of cultural competence in reducing the racial/ethnic disparities in health care access and outcomes [15]. In the US, only 19.5% of registered nurses identifi ed themselves as a member of a racial/ethnic minority [16].
This study focused on nursing students in three countries, one in North America, one in Central America, a third in sub-Saharan Africa, and was concerned about the students' future practice as licensed or practicing nurses as it might be impacted by attitudes, knowledge, and beliefs about HIV.
In Cameroon, approximately 660,000 people are living with HIV, with a prevalence rate for adults of 4.8%. In Honduras, the prevalence rate is .4%, representing 23,000 people. The US has a similar prevalence rate of .4%, representing somewhere between 920,000 to 1,800,000 individuals [1].
Nursing educators are responsible to ensure that the curriculum provides students with an adequate knowledge of HIV/AIDS. Factual knowledge is a critical fi rst step in order that students are able to deliver high quality care to persons living with HIV/AIDS; however, accurate knowledge alone is insuffi cient, and must be operationalized with care and compassion, and framed within a culturally appropriate context. This study examined the impact of a peer-to-peer training workshop on HIV/AIDS knowledge, attitudes, and beliefs for nursing students in Cameroon and Honduras.

Cultural context
The Republic of Cameroon has the fi fth largest population in West Africa with a population of 20,128,000 with a current life expectancy of only 54 years [17]. It is estimated that 560,000 persons were living with HIV/AIDS in Cameroon in 2010, representing a prevalence rate of 5.1%, and it is projected that more than 37,000 will have lost their lives in 2010 [18].
Cameroon, like many other African nations is challenged with building capacity to respond to the epidemic. Cameroon has 12 schools, colleges, or universities that provide nursing education.
Yearly, each of these educational organizations graduates 30 to 50 nurses with a variety of educational preparation. The most frequently occurring degree is the BSc.  [19]. The American students in this study were pursuing a baccalaureate degree in nursing program situated in a Midwestern major metropolitan area. One of the courses they were enrolled in was a seven week elective course titled HIV: Caring and Concepts which provided general information including the disease trajectory, care and management, and pertinent ethical issues. The teaching approaches included discussion, lecture, media and student projects, both as individuals and small groups. The students met after class to develop the modules they later would use to present content in Cameroon and Honduras.

Culture care theory
The theory of Culture Care Diversity and Universality emphasizes nursing as a means to know and help cultures [20] and to provide care measures in harmony with an individual's or group's cultural beliefs, practices, and values. Culturally based care factors are known to infl uence human responses to health, illness, well-being, or when confronted with death and disabilities. Leininger's theory postulates that in order for nursing care to be meaningful and benefi cial, it must be conceptualized in ways that show the interrelationships of care to culture, as well as to different cultures [20]. The theory includes three action modalities that are necessary for providing nursing care that is culturally congruent [21]. These modalities, or decision modes, help cultures retain, preserve, or maintain benefi cial care beliefs and values. Beliefs and values enable people within a culture face handicaps and death, adapt or negotiate with others for culturally congruent care for their health or deal with illness or dying. Successfully facing these challenges allows people to change or restructure their ways of life and institutions for better health care practices and outcomes [20].
In addition to culture, another major factor of this theory pertains to social structure factors. Important social structure factors include religion or spirituality, kinship or social ties, politics, education, technology, economics, and political factors. The theory predicts that these factors infl uence health and well-being both directly and indirectly.

Purpose
The primary purpose of this quasi-experimental prospective cohort study design was to examine changes in HIV/AIDS knowledge, beliefs, and attitudes of HIV/AIDS between nursing students in Cameroon, Honduras, and the United States across cohorts of a peer-led, train-the-trainer four-day workshop.

Methods
The quasi-experimental prospective cohort design was employed to evaluate the effect of an educational intervention on student nurses' knowledge, attitudes, and beliefs of HIV/ AIDS among senior level nursing students. As an educational and training grant, IRB groups in Cameroon, Honduras, and United States were provided all proper ethical and educational reviews and acceptances. To prepare for these various trainthe-trainer programs, the US students were prepared with content knowledge, teaching practices and practice activities.
Six weeks before the trip, US students participated in weekly learning activities to learn more about HIV, cultural infl uences, and classroom expectations. Cultural contexts were discussed as well as language reviews before traveling to the countries.
Inclusion criteria for all students was that they were in nursing program and spoke and read English. Faculty were available during the educational sessions to provide support but did not engage in the teaching.

Sample and setting
Cameroonian students were on a weeklong break from The Nurse Willingness Questionnaire (NWQ) [24] was developed in the US to measure nurses' willingness to provide direct care activities to a patient with AIDS. Previous studies suggest that the NWQ is a reliable and valid instrument for evaluation of nursing students as well, with Cronbach's alpha of .94 [26]. The AIDS Attitude Scale (AAS) uses a 5-point Likert scale (1 = strongly agree to 5 = strongly disagree) to rate 21 items [4]. Examples of the statements include, "I would not like to have a friend who is a known homosexual" and "most people with HIV/AIDS have only themselves to blame". Reliability coeffi cients ranged from .85 to .90 and validity was confi rmed by review of the scale in three rounds by separate groups of nursing faculty [4]. When questions arose that the students could not answer, the faculty were there to provide assistance. When the workshop concluded the participants completed the set of questionnaires.
The set of questionnaires was repeated again 60 days later.

Results
The three sample groups differed statistically by age, gender, relationship status, HIV status, knowing someone HIVpositive, knowing someone who has died of AIDS complication, as well as knowingly given nursing care to someone with HIV/ AIDS. All were signifi cantly different except for gender and sexual orientation ( Table 1).
Each of the fi ve surveys will be discussed separately. The

Discussion
The peer-to-peer training has been demonstrated to be an effective method of learning in a variety of settings and professions [29][30][31][32]. This study also demonstrated that delivering the information in Spanish, there could have been some translation issues. While faculty were available during the content delivery, the students presented the content from their level of knowledge.

Implications for practice
Practice brings a plethora of understanding in caring for HIV/AIDS. The knowledge one brings to the clinical area will impact the role of HIV testing, HIV/AIDS care, and assisting caregivers in their role. Access to care is critical in developing countries and understanding how the need for antiretroviral medications are to the health of individuals is necessary within all clinical setting. Helping to change beliefs and practices will only improve the health and wellbeing of those infected and affected with HIV. In addition, fi nding new ways to educate and motivate new nursing students to practice using evidence based information is a challenge.

Implications for education
Building capacity for HIV/AIDS education among nursing students is an imperative strategy for global prevention and treatment of PLWHA. The focus and approach of education should be targeted to address inadequacies within a culture and tailored to meet the personal and professional experiences of students regardless of national sero-prevalence. Providing clear and accurate information will help to reduce the myths surrounding the disease and provide a more positive view in caring for HIV/AIDS patients within the community. Educational interventions which are based on train-the-trainers and peerled learning approaches are not only practicable, they are effective as well.

Implications for future research
Implications for future research should include additional cultural comparisons, other clinical and caregiver roles, as well as behavior and competency follow-up of licensed nurses. Long term studies following the students one and two years after the intervention might reveal a new understanding of how stigma was reduced over time. Once students have transitioned in their roles as practicing nurses, it might be relevant to see how their understanding has changed after caring for those living with HIV/AIDS.

Conclusions
Building capacity for HIV/AIDS education among nursing students is an effective strategy across the globe, especially in areas that lack an abundance of resources including highly prepared faculty and educators. The focus and approach of such instruction should be tailored to meet the personal and professional experiences of such students. The innovative and effective method of peer-to-peer training can also be applied within a resource-limited setting to expand the message's impact. Additional layers of student cohorts or variation across setting location may demonstrate this training method's infl uence in educating the nursing workforce.
Cameroonian perceptions of perceived stigma and attitude regarding HIV/AIDS were substantially worse than those from the nations with lower sero-prevalence. Honduran willingness to provide care was higher, but eventually met by the other cohorts following the educational curriculum. Gains by the Cameroonian and American cohorts dropped off at the delayed follow-up. Both the AKS and the OKS questionnaires highlighted a lag in knowledge amongst the Honduran participants, who were in a less rigorous curriculum. American scores for stigma, attitude, and general knowledge were relatively unchanged by the didactic educational method.