Comparison of knowledge, attitude, and practice of healthcare staff toward sexually transmitted infections in Markazi Province, Iran

Introduction

Sexually transmitted infections (STIs) are known as the most common acute diseases in the world [1]. Among sexually transmitted infections, Chlamydia trachomatis (chlamydia), Neisseria gonorrhoeae (gonorrhea), Trichomonas vaginalis (trichomoniasis), and Treponema pallidum subspecies pallidum (syphilis) are the curable ones [1, 2].
In recent years, the United States have experienced an increase of STIs incidence. Between 2013 and 2017, studies have shown a 67% increase in gonorrhea and a 35% increase in chlamydia [3, 4]. According to World Health Organization (WHO) reports, more than 1 million STIs cases are detected every day. Globally, more than 500 million people are living with genital HSV (herpes) infection and 240 million are living with chronic hepatitis B, both of which can be prevented by vaccination. In 2016, there were one million pregnant women with syphilis [5]. Although, the incidence and prevalence of the four sexually transmitted infections are lower in Europe than in other regions, a significant burden of these diseases can be observed in Europe, most of which is related to chlamydia [1, 6].
Sexually transmitted infections mainly affect sexual and reproductive health [7]. These infections spread mainly through unprotected sexual relationships. They can also be transmitted during pregnancy and childbirth, and through infected blood or blood products [8], which cause fetal and infant death, infertility, increased risk of human immunodeficiency virus (HIV) transmission, and psychological and social consequences [9]. STIs are often accompanied by unpleasant consequences, including stigma, stereotyping, vulnerability, and shame, and are associated with gender-based violence [10].
The notion of a reduced risk of HIV infection during antiretroviral therapy (ART) and pre-exposure prophylaxis (PrEP) is associated with reduced condom use and increased transmission of other STIs [11]. STIs, except HIV, impose a high burden of mortality and morbidity in developed and developing countries. The World Health Organization’s Global Strategy for the prevention and control of STIs was presented in May 2006. Adoption and implementation of a global strategy followed by member countries of the World Health Assembly provide a good base to achieve the millennium development goals. These goals include programs and measures to prevent and control sexually transmitted diseases [12], safe and effective vaccination against hepatitis B virus (HBV) and human papilloma virus (HPV), which cause major consequences in the global health [7].
In Iran, religious beliefs and social structure lead to non-reporting of symptoms of sexually transmitted infections [13], but it can be estimated that the prevalence of sexually transmitted infections in Iran is widespread (gonorrhea: 4.1% and chlamydia: 20%) [14-16]. Knowledge and practice of healthcare providers about syndromic management of STIs were insufficient [17-19], since a person’s knowledge of a disease positively affects attitudes toward prevention, and thus changes practice [20]. Therefore, physicians and health staff’s awareness, due to their important role in the prevention and treatment of STIs, can be the basis of proper health practice. It is necessary to know the basic status of knowledge, attitude, and practice (KAP) in a target population. In Iran, no studies have been conducted to examine knowledge, attitudes, and practices of physicians and healthcare providers about sexually transmitted infections. Therefore, the main aim of this study was to assess KAP on STIs among health service providers in Markazi Province.

Material and methods

This cross sectional study was conducted between September and November, 2019. Prior to commencing the study, ethical clearance was sought from the Markazi University of Medical Sciences. In order to evaluate scores of knowledge, attitude, and practice related to STIs in healthcare staff (physicians, health professionals, and midwives) in the Markazi University of Medical Sciences, a 32-item self-made KAP questionnaire as a research tool has been developed. In order to assess content validity, a panel of professionals in the field of STIs examined the questionnaire. After receiving opinions of professionals on each of the questions, the questions that did not obtain validity score according to standards were removed. To evaluate reliability, pre-test was completed with 30 individuals, and Cronbach’s α was estimated as 0.8. The questionnaire consisted of four parts. In the first part of questionnaire, participants were asked to provide information about demographic variables (6 items), such as gender, age, and education. The second, third, and fourth parts assessed participants degree of knowledge (12 items), attitudes (10 items), and practices (10 items). Negative questions were re-coded before data analysis, so that a higher value represented a stronger endorsement of the construct measured by each scale. The questions evaluating knowledge, attitude, and practice sections had the highest scores of 24, 50, and 40, respectively, and the lowest scores of 0, 10, and 10, respectively. Knowledge, attitude, and performance scores were divided into three levels (knowledge scores: 0-12 = ‘poor’, 13-18 = ‘average’ and 19-24 = ‘desirable’; attitude scores: 10-25 = ‘poor’, 26-40 = ‘average’, and 41-50 = ‘desirable’; performance scores: 10-20 = ‘poor’, 20-30 = ‘moderate’, and 30-40 = ‘favorable’).
Study population and sampling
Initially, Cochran’s formula was used to calculate sample size. The size of statistical population was 567 and Ζ = 1.96, p = 50%, d = 0.05; therefore the sample size was calculated as 229. For this cross-sectional study, participants were selected using a stratified sampling method. In this way, a list of each category was prepared, each person was coded, and then, individuals were selected using a random number table in Excel. Accordingly, 40 physicians, 99 health professionals, and 87 midwives working in health centers of the Central University of Medical Sciences were enrolled, and finally, 226 participants were investigated. Having at least one year of experience in health centers under the health deputy of Markazi University of Medical Sciences was considered as a criterion for inclusion in the study, and change of workplace from health deputy to other deputies was considered as an exclusion criterion. All participants have signed an informed consent at the beginning of the study. Ethics approval of this article has been granted by the Research Committee of Markazi University of Medical Sciences (No., IRARAKMU. REC. 1398. 114).

Statistical analysis
Survey answers were collected from 226 participants in Excel. Normality of qualitative data was assessed with Kolmogorov-Smirnov and Shapiro-Wilk tests. Knowledge, attitude, and practice were not normally distributed, so Mann- Whitney test, Kruskal-Wallis, Dunnett’s multiple comparison, and Bonferroni correction were all used to compare median and interquartile range (IQR) score of knowledge, attitude, and practice among participants. A significance level of 0.05 was considered. Data were analyzed in SPSS software version 21.

Results

In this study, within 3 months, 217 women and 9 men in the age range of 20 to 43 years were investigated. The results showed that most of the participants were women (96%) and majority of them were within the age range of 20 to 30 years (94 individuals, 41%), 69% of the participants were married, and 43% were health professionals. Most of the respondents had not passed a course related to STIs (46%). The mean age of the participants was 33 years, with a standard deviation of 7 (Table 1).
To evaluate the score of knowledge, attitude, and practice across various levels of demographic variables, Kruskal- Wallis test and Mann-Whitney test were applied.
According to the results shown in Table 2, the use of Kruskal-Wallis and Mann-Whitney tests indicated that there was a difference in knowledge among physicians, midwives, and health professionals. As expected, health professionals had lower median score than midwives and physicians: 12 (4), 15 (3), 15 (3), p < 0.001, respectively. There was no significant difference in gender, between men and women (p = 0.42). As can be seen in Table 3, physicians and midwifes attained further median (IQR) attitude comparing to health professionals: 30 (5), 30 (8) vs. 27 (8), p = 0.025, p = 0.007, respectively.
Individuals aged 30 to 40 years had higher median (IQR) practice score than those aged 20 to 30 years: 32 (7) vs. 29 (11), p = 0.02. Also, midwives had better median practice score compared to health professionals: 32 (6) vs. 29 (10), p = 0.002. Among individuals with less than 5 years of work experience and those who had 10 to 20 years of work experience, there was a significant difference in median practice score: 29 (10) vs. 31 (9), p = 0.04 (Table 4).
Approximately, 61% (140) of the participants’ knowledge score was within moderate range. The attitude of 71% of the respondents was moderate, and the practice of 47% was favorable. Practice total median score was 30 (Table 5).
Table 6 shows that only 8% and 12% of the participants performed well in counseling patients and advising them to get tested for HIV. There was a negative attitude towards prevention and treatment. The use of national guidelines was low, but overall performance was good.

Discussion

Previous studies in Iran did not examine knowledge, attitude, and practice of physicians and healthcare providers. Therefore, this paper aimed to demonstrate KAP score toward STIs. to physicians and healthcare providers.
In this study, the median knowledge score was the same among different age groups, and there was no difference between married and single people. Also, the median knowledge score between participants with different work experience was the same, and difference between the times of last training sessions was not seen. This may be due to the fact that the concepts taught have not been changed in different years. In the present study, there was no difference between men and women toward knowledge, and attitude and median score of knowledge was intermediate. This was probably because all of the participants had access to the same instructions and had received the same training. According to the results of studies conducted in Pakistan and Namibia, the knowledge of general practitioners was 55.3% and 56.5%, respectively [17, 18], which were less than in our study. In South Ethiopia, clinicians’ knowledge about STIs was meager (27.2%). Clinicians who worked in health centers were more aware of urinary tract secretions than those working in hospitals [19]. In Kabul, most healthcare providers were informed of HIV and hepatitis [21].
In this study, knowledge scores in different groups of education and occupation were not the same. In this regard, attitude and practice were different in occupational groups. This may be due to differences in the extent, to which physicians, healthcare providers, and midwives intervene in the treatment and guidance of people with sexually transmitted infections. Basically, the midwife is more in touch with these people. In a study in Iran, researchers said getting help from infected people was effective in educational programs [22]. The results of an educational intervention in India showed that knowledge and attitude of students and healthcare providers were improved after the intervention [23]. Theories suggest that knowledge depends on belief and attitude, and that behavior change depends on learners’ readiness and willingness [24]. More training sessions are not necessarily associated with increased level of knowledge. Shorter and fewer meetings are more effective [25]. Even with the help of a short-term and occasional periodic training strategy, refreshing their information even at lunch helps to improve service delivery [26]. In our study, physicians and midwives had better knowledge toward STIs than health professionals. In line with our study, Machowska’s study revealed the same finding about HIV [23] that it can be due to more training of physicians [27].
General adherence to national management of STIs was poor in our study. Physicians and healthcare providers, in particular midwives, had to be trained, but most of them did not receive enough training. Our finding about adherence to national guideline was different from Ethiopia and Namibia [18, 19]. In South Africa, general knowledge of STIs in doctors and nurses from public and private clinics was not optimal, and the use of national STIs management guidelines by them was low [26]. Mtengezo et al. reported that there was no difference between nursing students and healthcare providers in terms of knowledge of infectious diseases, such as HIV/AIDS, but attitude of health staff toward healthcare providers and students was negative [28].
In the present study, attitude toward STIs was more in the desired range (71%). In a study conducted on students as future healthcare providers in Malaysia, attitude about protective effect of condom on sexually transmitted diseases was 41.7%, and they disagreed that multiple partners have no role in transmitting the disease [29]. The attitude of medical students is potentially important because it can lead to social stigma, social exclusion and avoidance of necessary care, negligence and evasion of people living with a disease, such as HIV/AIDS, leading to discrimination in treatment of people living with HIV/AIDS. Moreover, it imposes additional costs on patient and health system. This negative attitude, in addition to discrimination and imposing additional costs, can lead to a further spread of the virus, and avoid proper care for patients and their families [30, 31].
As studies show, medical students have a low negative attitude towards sexually transmitted diseases, such as AIDS, and their education increases their experience and improves their attitude [32-35] that it can affect the practice. In our study, total practice was optimal and it seems that midwives had a better practice. Midwives perform better than general practitioners and health professionals because of the specialized courses they take during their educations, and dealing more with patients with genital diseases in their workplace. In the present study, there was a significant difference in terms of practice between married and single people, and married employees had a better practice. As other studies have shown, married medical students perform better [28, 35, 36]. This may be due to their direct involvement in sexual activity, and thus, they better understand the consequences of not following health tips during sex, which can lead to their better practice comparing to single people. In a study from Malaysia Health and Medical University, although students’ knowledge about sexually transmitted diseases (STDs) was high, significant predictors of knowledge and warning behaviors of sexually active students indicated that their practice was not at the desired level [29]. In a study in Iran, researchers stated that although knowledge of educated people about HIV and TB (tuberculosis) is higher, their practice is similar to people with different levels of education. High knowledge and positive attitude do not necessarily lead to behavior change, and comprehensive training programs are required [22]. Having a high knowledge does not guarantee midwives and doctors better practice comparing to health professionals. This shows that more training alone is not accompanied by better practice; thus, training must be effective.
This study was performed among health workers. Despite their lack of knowledge, their attitude and practice were at a good level. Among the professionals surveyed in this study, midwives were more knowledgeable than others and were more proficient in following the protocols. However, they were weaker in the counseling process. Providing help on prevention and use of condoms, HIV testing, etc., were done in less detail. This weakness indicates the need for more training in order to have better interaction and more effective communication with patients.

Limitations
The present study was the first survey on knowledge, attitude, and practice of health staff (health professionals and midwives) and physicians that was conducted in Markazi Province. The study was conducted among all groups of service providers, including physicians, midwives, and health professionals, and we used a self-made questionnaire according to the protocol for the prevention and treatment of sexually transmitted infections. One of the limitations of the study was the fear of healthcare providers about the impact of their low scores on their rights and benefits. Another weakness was non- segregating the questionnaires of midwives, doctors, and health professionals, as in the healthcare system, most of the actions related to people who refer with complaints related to diseases and sexually transmitted infections are among the responsibilities of a midwife. Another weakness of the study was lack of focus on a specific sexually transmitted infection.

Conclusions

The results of the study showed a moderate level of knowledge among the subjects. In this study, employees’ practice score was higher than their knowledge score. This is because they try to do their tasks routinely without realizing its’ importance, and having enough knowledge about it. Therefore, considering the importance of education and its’ impact on people’s practice, this study also emphasizes the provision of continuous health education to improve knowledge and increase positive attitude in healthcare providers. Assessing knowledge, attitude, and practice of health staff is the first step to provide optimal services to patients. The findings of this study help health policy-makers to improve measures and interventions related to improving knowledge, attitude, and practice of health staff.

Acknowledgment

We thank all the staff of the Markazi University of Medical Sciences who helped us implementing this project as well as all the participants in the research.

Funding source
The Arak University of Medical Sciences, Markazi, Iran.

Conflicts of interest

The authors declare no conflict of interest.

References