Nurses’ willingness to care for patients infected with HIV or Hepatitis B / C in Vietnam
Ishimaru et al. Environmental Health and Preventive Medicine
Nurses' willingness to care for patients infected with HIV or Hepatitis B / C in Vietnam
Koji Wada 0
Huong Thi Xuan Hoang
Anh Thi My Bui
Hung Dinh Nguyen
Derek R. Smith
0 Bureau of International Health Cooperation, National Center for Global Health and Medicine , Tokyo , Japan
Objectives: This study examined the factors associated with nurses' willingness to care for patients infected with human immunodeficiency virus (HIV) or hepatitis B or C virus (HBV/HCV) in Vietnam. Methods: A cross-section of 400 Vietnamese nurses from two hospitals were selected using stratified random sampling, to whom a self-administered questionnaire was administered which included demographic items, previous experience with patients infected with HIV or HBV/HCV, and their attitudes toward these patients. Data was analyzed using descriptive statistics and multiple logistic regression. Results: The lifetime prevalence of needlestick or sharps injury whilst caring for a patient infected with HIV or HBV/HCV was 9 and 15.8%, respectively. The majority of participants expressed a willingness to care for patients infected with HIV (55.8%) or HBV/HCV (73.3%). Willingness to care for HIV-infected patients was positively associated with being 40-49 years of age and confidence in protecting themselves against infection. Regarding HBV/HCV infection, willingness to care was positively associated with individual confidence in protecting themselves against infection. Conclusions: This study revealed that Vietnamese nurses were somewhat willing to care for patients infected with HIV or HBV/HCV, and this was associated with individual confidence in protecting themselves against infection and with negative attitudes towards HIV and HBV/HCV. Establishing a positive safety culture and providing appropriate professional education to help reduce the stigma towards infected patients offers an effective way forwards to improve quality of care in Vietnam, as elsewhere.
Hepatitis B; Hepatitis C; Human immunodeficiency virus; Nurse; Stigma
In Vietnam, patients infected with blood-borne diseases
have been known to suffer from stigma and
discrimination by healthcare workers , which is alarming given
that the national prevalence of infectious disease is
estimated to be 12.0% for hepatitis B virus (HBV), 2.0%
for hepatitis C virus (HCV), and 0.5% for human
immunodeficiency virus (HIV) [2, 3]. The primary transmission
routes in Vietnam are believed to be prenatal transmission
for HBV , injectable drug use and hemodialysis for
HCV , and injectable drug use and unsafe sexual
contact for HIV . Since 2006, the government has
prohibited refusal of care or discriminatory treatment against
any patient infected with HIV , yet most hospitals still
lack a formal policy and hospital practices to eliminate
stigma and discrimination on this issue [8, 9]. Previous
studies have suggested that injectable drug use and
commercial sex were still considered as “social evils” in
Vietnamese society; and these social mores, in turn, have
the effect of strongly stigmatizing attitudes of healthcare
workers toward patients infected with HIV [10, 11].
Nurses sometimes hold negative attitudes toward patients
infected with HIV [12–15], HBV or HCV [16–18].
Providing care for such patients may put health professionals at
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risk for acquiring an infection, with the risk following a
contaminated needlestick or sharps injury being estimated
at between 6 and 30% for HBV, 1.8% for HCV, and 0.3% for
HIV . Although HBV infection can largely be prevented
by vaccination; there is currently no effective vaccine for
HIV or HCV, and a lack of effective post-exposure
prophylaxis for HCV . As such, risk perception may influence
nurses’ unwillingness or refusal to care for patients with
blood-borne diseases .
Positive attitudes toward patients infected with HIV or
HBV/HCV represent an essential element in the
appropriate care of such individuals. Nevertheless, few studies have
investigated the factors affecting attitudes of Vietnamese
nurses toward patients infected with HIV or HBV/HCV.
This study was designed therefore, to examine the factors
associated with nurses’ willingness to care for patients
infected with HIV or HBV/HCV in Vietnam.
Materials and methods
Participants and procedure
We conducted a questionnaire study of Vietnamese
nurses in February 2016. According to a report from the
Vietnam Ministry of Health in 2008, 63,040 nurses were
registered in Vietnam and were distributed as follows:
13% in central hospitals, 44% in province hospitals, 27%
in district hospitals, and 17% in community hospitals
. Nurses in Vietnam are recognized in three
categories depending on education levels (secondary educated
nurses, college educated nurses and bachelor degree
nurses). Secondary medical schools provide 2-years of
training for nurses, junior colleges provide 3-year
training for nurses, and universities provide a 4-year bachelor
of nursing degree. All courses require 12-years of
compulsory education for admission. Regardless of the
different levels of their nursing education, however, all nurses
work at the same level and scope in the clinical
environment. The role of each nursing degree are currently
under examination in Vietnam.
The target population for this study was nurses from
two general hospitals located in Hanoi, Vietnam where
patients infected with HIV, HBV or HCV were routinely
cared for. Hospital A was 570 beds along with 500
nurses and Hospital B was 240 beds along with 300
nurses, respectively. Stratified random sampling was
employed, with recruitment ceasing when 400
participants had joined the study (comprising 250 from
Hospital A and 150 participants from Hospital B). The study
questionnaire was completed anonymously and
participants gave their written and oral informed consent. Each
participant was paid 30,000 VND (approximately 1.5
USD) as a financial reward. The study was approved by
the Hanoi School of Public Health Institutional Review
Board (No. 016-004/DD-YTCC).
The questionnaire used for this study was adapted from
previous research that had been undertaken in Japan
. It was translated into Vietnamese using standard
translation procedures for cross-cultural studies [23, 24],
with some items being modified for the local context
following consultation with a panel of experts . We
collected information on demographics (gender, age,
marital status, nurse category, and career duration) as
well as previous experience caring for HIV or HBV/HCV
infected patients, measured with binary yes/no responses
to two questions: (1): professional contact with an infected
patient within the previous year, and (2): previous
needlestick or sharps injury (ever) whilst caring for a patient
infected with HIV or HBV/HCV. Attitudes toward patients
infected with HIV or HBV/HCV were examined using the
following questions: “confidence to protect against
infection during caring for an infected patient” (confidence);
“avoid going near an infected patient” (discrimination); and
“stigma that an infected patient is linked to homosexuality,
injectable drug use, or having multiple sex partners”
(stigma). Attitudes and willingness were assessed with two
separate sets of questions, one related to HIV and the other
to HBV/HCV. The dependent variable in this study was
willingness to care for patients infected with HIV or HBV/
HCV, and was measured as the participants’ level of
agreement with the following statement: “I would want to care
for a patient who is infected with HIV (or HBV/HCV)”.
Each statement regarding attitudes or willingness to care
was answered on a four-point Likert response scale (agree;
somewhat agree; somewhat disagree; disagree).
All variables were analyzed using descriptive statistics,
with multiple logistic regression analysis being used to
examine factors associated with nurses’ willingness to
care for patients infected with HIV or HBV/HCV.
Attitudes toward and willingness to care for, patients with
HIV or HBV/HCV were treated as separate outcomes.
The multivariable model included gender, age, marital
status, nurse category, working experience, professional
contact with an infected patient, and previous accidental
injection or exposure to a patient with HIV or HBV/
HCV. For the statistical analysis, attitudes toward
patients infected with HIV or HBV/HCV were reclassified
into three levels (1 = agree, 2 = somewhat agree, and 3 =
disagree/somewhat disagree), and the outcomes were
reclassified into two levels (1 = agree/somewhat agree, and
2 = disagree/somewhat disagree). We applied Zhang’s
formula for adjusting the results of common outcomes
. All data were analyzed using SPSS for Windows
17.0 (SPSS Inc., Chicago, IL, USA), with p values <0.05
interpreted as being statistically significant.
A total of 400 nurses participated in the study, among
whom, the majority were female, aged 20–39 years,
married, and Secondary educated nurses (Table 1). Around
half of participants (46.8%) had cared for patients
infected with HIV in the past year, while 71.0% had cared
for patients infected with HBV/HCV during this time
period. In their professional experience as a nurse, 9 and
15.8% reported experiencing a previous needlestick or
sharps injury while caring for a patient infected with
HIV or HBV/HCV, respectively. Table 2 shows the
frequency and distribution of attitudes toward patients
infected with HIV or HBV/HCV. The majority answered
“agree” or “somewhat agree” in response to the question
of willingness to care for patients infected with HIV
(55.8%) and HBV/HCV (73.3%). Approximately 70% of
participants agreed or somewhat agreed that they felt
Table 2 Attitudes Toward Patients Infected with HIV or HBV/HCV
Willingness to care for patients infected with HIV or HBV/HCV
Confidence to protect myself from infection when caring for patients
infected with HIV or HBV/HCV
Nurses’ education levels
Bachelor degree nurse
Professional experience (years)
Professional contact with patients infected with HIV or
HBV/HCV(within the past year)
Previous needlestick or sharps injury (ever) whilst caring
for a patient infected with HIV or HBV/HCV
HIV, Human Immunodeficiency, HBV Hepatitis B Virus, HCV Hepatitis C Virus
Avoid going near patients infected with HIV or HBV/HCV
Do you believe that patients infected with HIV or HBV/HCV might
be linked to homosexuality, injectable drug use, or have multiple
HIV Human Immunodeficiency, HBV Hepatitis B Virus, HCV Hepatitis C Virus
confident to protect themselves from infection while
caring for patients infected with HIV and HBV/HCV. While
the majority of participants reported non-discriminatory
and non-stigmatizing attitudes, some agreed or somewhat
agreed that they still avoided going near patients infected
with HIV (23.3%) and HBV/HCV (9.4%). In addition,
some participants agreed with the statement that linked
infected persons to homosexuality, injectable drug use, or
having multiple sex partners (32.0% for HIV, 18.6% for
Multivariate analyses revealed factors associated with
willingness to care for patients infected with HIV or
HBV/HCV (Table 3). Regarding HIV infection,
willingness to care for patients was positively associated with
being 40–49 years old (Odds Ratio (OR) 1.70, 95%
Confidence Interval (95%CI): 1.02–2.07), and confidence in
protecting myself against infection (agree: OR 1.97,
95%CI: 1.76–2.10; somewhat agree: OR 1.75, 95%CI:
1.48–1.94), and negatively associated with avoiding
infected patients (agree: OR: 0.27, 95%CI: 0.10–0.66;
somewhat agree: OR 0.61, 95%CI: 0.35–0.97) and being
a bachelor degree trained nurse (OR: 0.62, 95%CI: 0.37–
Table 3 Factors associated with willingness to care for patients infected with HIV or HBV/HCV
Confidence to protect myself from infection when caring for patients infected with HIV or HBV/HCV
Avoid going near patients infected with HIV or HBV/HCV
Nurses’ education level
Bachelor degree nurse
OR Odds Ratio, 95%CI 95% Confidence Interval, HIV Human Immunodeficiency Virus, HBV Hepatitis B Virus, HCV Hepatitis C Virus
0.95). Regarding HBV/HCV infection, willingness to care
for patients was only positively associated with
confidence to protect against infection (agree: OR 2.27,
95%CI: 1.66–2.80; somewhat agree: OR 1.74, 95%CI:
1.21–2.30); willingness was negatively associated with
the statement that linked infected persons to
homosexuality, injectable drug use, or having multiple sex partners
(agree: OR: 0.29, 95%CI: 0.12–0.66; somewhat agree: OR
0.33, 95%CI: 0.17–0.61) and with avoiding going near
infected patients (somewhat agree: OR 0.34, 95%CI:
This study investigated factors associated with nurses’
willingness to care for patients infected with HIV or
HBV/HCV in Vietnam. Our study revealed that nurses
who felt confident in protecting themselves against
infection were more willing to care for patients infected
with HIV or HBV/HCV, while nurses with
discriminatory attitudes towards HIV and HBV/HCV, and stigma
regarding HBV/HCV were less willing to care for such
patients. The findings offer important insights for
providing appropriate care for people infected with HIV,
HBV or HCV in Vietnam, as elsewhere.
Healthcare workers may experience an ethical dilemma
in deciding whether to provide treatment and care for
patients infected with HIV, HBV or HCV. For example,
unwillingness to treat patients with HIV has been reported in
23 to 50% of physicians in the United States, 21% in Spain
and 14% in Canada . The current study revealed that
the percentages of Vietnamese nurses unwilling to provide
care was similar to that reported among Japanese nurses
(44% for HIV and 27% for HBV/HCV in Vietnam; 46% for
HIV and 20% for HBV/HCV in Japan) . Some studies
have suggested that nurses may be more likely to give
differential care to infected patients when compared to their
medical counterparts [12, 29, 30], which may reflect
relative differences in their knowledge of infection .
Nurses’ knowledge of infection is probably variable in
Vietnam, due to the multiple education pathways to enter
nursing, the lack of a national licensing examination, and
the variety of practical training offered for newly graduated
nurses. Our findings suggest that hospital managers should
take action in this ethical dilemma among nurses so that
infected patients can receive appropriate care.
Having a positive safety culture in the health care
environment may improve nurses’ willingness to care for
patients infected with blood-borne infections such as
HIV, HBV or HCV. One study from Vietnam, for
example, reported that nurses’ compliance with standard
precautions was suboptimal, with 39% not washing their
hands following patient contact . Healthcare workers
in such situations may fear cross-contamination, which
may reduce their willingness to care for patients with
blood-borne infections [33, 34]. The current study
suggests that confidence in protecting oneself against
infection was a positive factor associated with willingness to
care for patients infected with HIV or HBV/HCV. In this
regard, positive safety culture, such as strict infection
control, may serve not only to protect healthcare workers but
also to improve the quality of patient care .
Avoidant attitudes were negatively associated with
willingness to care for patients infected with HIV and
HBV/HCV in the current study. Such attitudes towards
HIV, HBV and HCV are not uncommon in healthcare
[36, 37]. In Vietnam, caring for HIV positive patients is
often stigmatized due to the cultural contexts and
historical events related to the disease; meaning that nurses
often avoid going near infected patients for fear of suffering
prejudice from colleagues and family members [9, 10, 38].
As such, it can be seen that greater efforts are clearly
needed to improve the public image of patients with HIV,
HBV and HCV infection. Community prejudice against
individuals infected with blood-borne diseases is not limited
to Vietnam however, and has also been reported in other
Asian countries .
Our study suggests that stigma of nurses toward
patients infected with HBV/HCV was negatively
associated with willingness to care for them, while HIV stigma
had no such link to willingness. In general, it can be
suggested that individuals may harbor negative views
toward HBV and HCV infection, although these are less
stigmatized diseases when compared with HIV infection
. For example, some healthcare workers link patients
infected with HCV to injectable drug use and
uncooperative and problematic behavior in the wards [40–43]. Thus,
HCV-related stigma might affect their unwillingness to
provide care for such patients. Regarding HIV stigma,
some previous studies have reported an association
between homophobia and unwillingness to care for HIV
patients , which is inconsistent with results from the
current study. Further research is needed to clarify this
Middle-aged nurses may have more positive views
about providing care for patients infected with HIV in
Vietnam, with nurses aged 40–49 years being more
likely to express willingness to care for such patients in
the current study. On the other hand, a previous study
from Japan reported that nurses aged 50 years or older
were more stigmatized against HIV care, probably because
they worked during the beginning of the AIDS epidemic
. Vietnam has a higher community HIV prevalence
rate when compared to Japan (0.5% vs <0.1%) , and
additional experiences with HIV care probably bring
concomitant increases in knowledge and skills among
middleaged nurses; which may promote their willingness to care
for infected patients [15, 46]. Although educational
strategies clearly represent an appropriate strategy for reducing
HIV stigma and discrimination in healthcare practice ,
our study suggests that the healthcare worker’s age must
also be carefully considered.
Bachelor degree trained nurses were less willing to
care for patients infected with HIV than secondary
educated nurses in the current study. This result was
inconsistent with previous research which focused on the
length of education and professional license category
(nurse or nursing aide) [30, 48]. Because the majority of
nursing education in universities and colleges has been
performed by physicians in Vietnam, the educators of
physician tend to focus on medical management of
diseases rather than nursing care, which might negatively
affect nursing care for Vietnamese patients infected with
HIV. As such, future research should examine nurse
category-based differences in attitudes toward infected
The current study incurred a few limitations which are
worth considering. First, the study design was
crosssectional; and therefore, cause and effect relationships
could not be determined. Additionally, we conducted
the study in only two large public hospitals in Hanoi,
and the sample was relatively small (n = 400). As these
samples may not represent all nurses in Vietnam or
elsewhere; our findings should be interpreted with caution.
In conclusion, this study revealed that nurses were
somewhat willing to care for patients infected with HIV
or HBV/HCV, and this willingness was associated with
their confidence to protect themselves against infection,
and with their discriminatory or stigmatizing attitudes
toward groups of infected individuals. Establishing a
positive safety culture and providing appropriate
professional education to help reduce the stigma towards
patients infected with HIV, HBV or HCV offers an
effective way forwards to improve quality of care in
Vietnam, as elsewhere.
This study was funded by a grant from the National Center for Global Health
and Medicine, Japan (26-2). The funders had no role in study design, data
collection and analysis, the decision to publish or preparation of the
manuscript. The authors gratefully acknowledge the study participants and
staff from the hospitals for their support and cooperation throughout this
TI, KW, HTXH and ATMB conceived and conducted the study. TI and KW
contributed data analysis and results interpretations as well as drafting the
initial manuscript with DS. HDN and HL revised the manuscript. All the authors
read and approved the final manuscript.
The authors declare that they have no competing interests.
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
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