Study site, participants, and procedures
This study collected data from three different sites in a southwestern province in China. The study participants consisted of service providers who were currently working at general public health-care facilities in the area. Public health-care facilities in China are organized on six different levels: national, provincial, city/prefecture, county hospitals, township hospitals, and village health clinics. Generally, hospitals at higher levels serve a broader region and are more likely to have technologically advanced equipment and a more highly educated staff. Such hospitals have the capacity and resources to perform more sophisticated operations and are therefore also more likely to attract more patients.
In order to obtain a representative sample, we gathered staffing information from hospitals and clinics in the three study sites before sampling. We randomly selected three provincial hospitals, four city/prefecture hospitals, 10 county hospitals, 18 township health clinics, and 54 village clinics. The ratio of doctors to nurses in each hospital was used as our sampling scheme, and hospital laboratory technicians were over-sampled to allow for adequate representation in the analysis. A total of 1101 randomly selected service providers participated in the self-administered survey between January and August 2005, with less than an 8% refusal rate. All survey data were collected anonymously.
Study protocol, survey instruments, and informed consent forms and procedure were reviewed and approved by the Institutional Review Boards (IRB) of the University of California and China Centers for Disease Control and Prevention. Individual informed consent was obtained prior to participation in the survey, and a $10 gift was given to study participants for their participation.
The Health Professional Survey, developed specifically for this project, contained a total of 172 questions assessing participants’ demographics, medical training, experience, and attitudes and behaviour towards AIDS patients and PLWHA in general. summarizes the questions and scales used in this study.
Health professional survey questions and scales used
Mandatory HIV testing endorsement among providers was assessed for three distinct patient groups: for all patients with high-risk behaviour, for all patients before an operation, and for everyone admitted to the hospital. Responses to each statement ranged from 1 (strongly agree) to 5 (strongly disagree). The responses were dichotomized to agree (1) or disagree (0) for bivariate and multivariate analyses. Mandatory HIV testing endorsement for everyone admitted to the hospital was considered the main dependent variable.
General prejudicial attitude
was measured based on the 12-item priority stigma indicator defined in the HIV/AIDS-related Stigma and Discrimination Indicators Development Workshop Report
In the present study, we adapted nine items from the original scale, scored from 1 (strongly agree) to 5 (strongly disagree). The directions of some items were reversed so that the higher score indicates a higher degree of general prejudicial attitude. Acceptable consistency reliability was supported by an α value of 0.75.
Perceived structural support was measured by the 10 items listed in . The original responses for each statement were 1 (yes), 2 (no), or 3 (not sure). We revised the original scale to 0 (no), 1 (not sure), or 2 (yes) and developed a continuous scale in which higher numbers indicate higher levels of perceived institutional support. The inter-item reliability of this scale is acceptable with a value of Cronbach’s α at 0.70.
Perceived infection risk at work was constructed by the combination of three questions. Survey participants responded to each of the three questions with a response category ranging from 0 (not possible) to 3 (high possibility). In this scale, a higher number was associated with higher perceived risk of HIV infection at work (Cronbach’s α = 0.70).
Knowledge of HIV/AIDS was formed by 10 questions; these questions have been used, together or separately, in many HIV studies to measure HIV-related knowledge. For each item, the response was coded as 1 (correct answer) or 0 (incorrect answer or unknown). The scale for HIV/AIDS knowledge was constructed as a sum of all 10 items.
Demographic information of the providers included age, gender, ethnicity (Han or minority), medical education (less than associate degree, associate degree, or medical degree/higher), level of care (provincial/city, county or township/village), professional category (doctor, nurse, or laboratory technician), personal contact with PLWHA (yes or no), and HIV-related training status (yes or no).
All analyses were performed using SAS statistical software (SAS Institute, Inc., Cary, NC, USA). Descriptive statistics were performed to assess the relationships between providers’ mandatory HIV testing endorsement and their demographics, medical education, level of care, profession, personal contact with PLWHA, and HIV-related training experiences. Pearson correlation coefficients were calculated to assess the relationship between mandatory HIV testing endorsement and general prejudicial attitude, perceived structural support, perceived risk at work, and HIV knowledge. Further, a series of multiple regression analyses were conducted to examine associations between mandatory HIV testing endorsement, general prejudicial attitude, and perceived structural support; controlling for the simultaneous effects of participants’ age, gender, ethnicity, medical education, personal contact with PLWHA, the level of care, and perceived risk of HIV infection.