HIV and AIDS related knowledge, sources of information, and reported need for further education among dental students in Sudan- a cross sectional study

Sudan is the largest country in Africa with a prominent diversity in; culture, religion, languages and ethnicity. Being bordered by nine countries, some having a high prevalence of human immunodeficiency virus infection and acquired immunodeficiency syndrome (HIV and AIDS) and having experienced long term ethnical and political conflicts, Sudan is vulnerable for an increase in the prevalence of HIV and AIDS [1]. The first case of HIV and AIDS in Sudan was reported in 1986 and in 2002 the total number of cases reported had increased to 4004 [1]. As in other sub Saharan African countries, the main mode of transmission is heterosexual, accounting for 97% of the HIV positive cases. According to a population based study conducted in 2002, the sero-prevalence was estimated to be 1.6% [1]. Among women attending antenatal clinics, sex workers, prisoners, soldiers, subjects infected with sexually transmitted diseases (STDs) and university students the prevalence of HIV and AIDS has been estimated to vary between 0,5% (soldiers) and 4.4% (sex workers). Moreover, evidence suggests that the HIV and AIDS prevalence among blood donors in Sudan have increased from 0.15% in 1993 to 1.4% in 2000 [1]. Sudan is currently recognised by the World Health Organization, [2] to be a country with an intermediate HIV and AIDS prevalence [1]

It is generally accepted that both dentists and other health care workers should provide quality treatment and care to all individuals indiscriminately [3]. Dentists have a professional and ethical responsibility to provide treatment to patients with HIV and AIDS, particularly since oral lesions, such as hairy leukoplakia, candidiasis and Kaposi's sarcoma, are commonly found in HIV-infected patients [4, 5]. Thus, Dental associations (Canadian Dental association, American Dental Association) have issued the recommendations that dentists are obliged to provide quality care for patients with infectious diseases, including HIV and AIDS. Because of the possible transmission of HIV virus through direct contact with blood, the risk for cross-infection comes into particular focus in dental practices [6]. Cross-infection can theoretically take place from patient to patient, from dentist to patient and vice versa. The estimated risk of HIV transmission from general practice dentists to their patients is recognized to be minimal if infection control guidelines are strictly adhered to. About 90% of the HIV infections among health care workers occur in developing countries where occupational safety is a neglected issue [7].

Fear of HIV contagion generates major concerns among health care personnel and may produce a barrier to successful educational efforts about AIDS. This might lead to a variety of adverse outcomes such as unwillingness to treat AIDS patients altogether [8]. Fear about contagion or AIDS phobia have among other things been attributed to lack of proper knowledge about HIV and its transmission routes [9]. It has been suggested that health care workers are deficient in appropriately managing and counseling HIV and AIDS patients and lack sufficient knowledge of symptoms as well as how to diagnose and treat infected patients appropriately [10, 11]. A study among medical students in the United States of America revealed that over half of the students investigated believed that treating AIDS patients might be hazardous and that their education had not prepared them to treat those patients safely [8]. In a study from United Kingdom, dentists demonstrated good knowledge regarding oral lesions associated with HIV and AIDS, but were less familiar with HIV and AIDS transmission routes [12]. Among Tanzanian health care workers inadequate knowledge of treatment procedures related to HIV and AIDS caused reluctance with respect to providing care for HIV-positive patients [13]. Few medical students in Pakistan were found to have accurate knowledge regarding symptoms of HIV and AIDS and modes of HIV transmission, while most of them expressed a need for further education [11]. Similar findings have been reported among Turkish nurses and dentists in Kenya, Brazil, Singapore, South Africa and Iran [14–18]. In Sudan, however, only limited information is available in this area.

One major step in preventing a widespread HIV-infection and AIDS epidemic in Sudan is to make certain that dentists are prepared to recognize and treat HIV infected persons and to counsel patients about risks that might lead to infection. Valid knowledge about HIV transmission routes and the HIV epidemiology is important in light of the increasing epidemic and since students are in a process of developing into their subsequent role as dentists in clinical practices. Dental students in Sudan are trained in the epidemiology; the microbiology and pathology (agent, immunology, course and manifestation); and precaution and prevention of HIV during their basic years (1st and 2nd years). In the 3rd, 4th and 5th years students' encounter with HIV patients becomes more apparent. It is upon this background that the present study set out to assess HIV and AIDS related knowledge, sources of HIV and AIDS related information, and perceived need of further education in dental students attending public and private dental schools in Khartoum. Information regarding dental students' HIV-related knowledge provides a crucial foundation for efforts aimed at developing a curriculum that provides clear and consistent information regarding HIV and AIDS and might attract dental school educators' attention to the subject of HIV and AIDS in Sudan.

The present study is the first to assess detailed knowledge regarding the modes of transmission of HIV-infection, related aspects of infection control, sources of HIV information and perceived need for further education regarding HIV and AIDS among Sudanese dental students. The findings are believed to be representative for dental students attending 3^rd, 4^th and 5^th study year in Sudan since a census of available dental schools in Sudan was considered with a high response rate. The study group targeted represents a restricted range of adults regarding age and socio-economic background making it less probably that social inequalities have contributed largely to the pattern of results. On the other hand, universities might vary regarding their format of instructions and in their atmosphere. Thus, universities vary regarding the type of students they attract. This was apparent in that public dental schools tended to have more female students and fewer smokers than the private dental schools. In addition, private dental schools encompassed older students living outside Sudan probably reflecting the higher socioeconomic status necessary of being in the position to attend private universities. In accordance with the demography of all higher educational institutions in Sudan, a larger proportion of females than males participated in the present study, reflecting the general progress in girls' education going on in this country.

As shown in Table 3, the present results suggest that dental students who should be aware of the latest information regarding HIV and AIDS demonstrated moderate to good overall knowledge with proportions having correct sum scores on occupational risk groups, transmission through contamination and transmission through shaking hand and eating ranging from 38% to 86%. Moreover, the percentages having correct knowledge varied from 35% (truck drivers as occupational risk groups) to 97% (transmission through contaminated blood transfusion). These figures show little difference from those obtained regarding the knowledge level in the general population of 15–24-year-olds from various countries, suggesting that about 50% have serious misconceptions regarding HIV transmission. Lack of knowledge was also apparent among the Sudanese dental students in that only 10% and 35% of students correctly classified teachers and truck drivers as occupational risk groups. Similar proportions of subjects having misconceptions with respect to HIV related issues have been identified in previous studies from industrialized as well as non-industrialized countries [12, 15, 17, 18, 20, 21]. On the other hand, Brook [22] found relatively sufficient knowledge about transmission routes and high-risk group among Israeli high school students. It should be noted that knowledge of the risk of being infected with HIV attributed to occupational groups, such as teachers and health care workers are seldom certain. Thus, there is disagreement among experts as to the relative importance of those groups when it comes to their susceptibility for infection. Such disagreement might explain differences in terms of private school students rating the vulnerability of university students, truck drivers and teachers higher than did their public dental student counterparts, whereas public dental school students rated the vulnerability of health care workers higher than did private dental school students.

The observation that a substantial proportion of the participants (79%) were concerned about the risk status of health care workers might reflect a fear of contagion among dental students. Previous studies have suggested that between 26% and 90% of students of medical subjects are concerned about HIV transmission from patients [8]. It is evident that students' beliefs that working with AIDS patients endangers their health might develop into an unwillingness to treat AIDS patients altogether [23]. Generally, knowledge about HIV infection is recognized as a critical component for the control and management of this disease [24]. Several authors have attributed fear of contagion to inadequate HIV and AIDS related knowledge, whereas others have demonstrated a reduction in fears through improved AIDS education [11, 25]. Apparently, there is a need for better professional education concerning HIV and AIDS among health care workers throughout the world. Proper training in medical and psychological aspects of treating HIV positive patients has been recognized as an effective method to change the attitudes towards HIV and AIDS among dental health care workers [25, 26]. Evaluations of public educational programs in developed- and developing countries dealing with prejudice reveal that the media images of the epidemic gradually become more positive and informative leading to a gradual shift in attitudes among health care workers.

Although a majority of the Sudanese dental students were aware of the common transmission routes for HIV infection, their knowledge was less accurate with respect to other HIV- and AIDS related topics. About half of the students investigated reported need for continued education considering HIV and AIDS and admitted having received much information on from media/reading material and lectures/health care workers (Table 2). The consistency of the present findings suggest that Sudanese dental students might be less well prepared for the task of treating patients with HIV infection and AIDS and that the dental school curriculum regarding HIV and AIDS needs some improvements. The finding that between 75% (basic HIV related issues) and 81% (clinical manifestations and psycho-social complications) of the participants reported a need for further education also suggests a recognition made by them of AIDS being a threat to the Sudanese society. These findings are similar to those reported by American and European investigators one decade ago when the AIDS epidemic was emerging [27]. Consistent findings have also been reported previously in studies from developed and developing countries [17, 18, 23, 28]. A recent study of dentists in Kenya revealed that the majority reported having a need for further HIV and AIDS education [16].

Lectures (61%), media (44%) and health care workers (39%) were the most frequently reported sources of HIV information among both public and private dental students. The sources of AIDS information reported in this study are similar to those identified previously among dental health care workers from Europe, USA, Japan and Iran, as well as in students of medical subjects from Iran and Pakistan [14, 26]. The present results are in contrast to a study of Japanese dental health care workers where TV and newspapers were cited as the most common source of AIDS related knowledge [26]. Sudanese dental students rating TV and Radio as a less common AIDS informational sources this has to be viewed in light of how this topic has been evaluated by the Sudanese national media. Recognized as sensitive sexually related issues, Sudanese media has not yet been in favor of public educational campaigns considering HIV and AIDS [29]. Dental health care workers in Netherlands and Italy cited scientific journals and continuing educational courses as their most important source of HIV related information. In contrast, Sudanese dental students reported dental reading materials as a relatively less common source of information thus highlighting a deficiency in their current education curricula concerning HIV and AIDS.

Analyzing all sum scores of HIV-related knowledge according to demographic covariates in multiple logistic regression analyses made it possible to control for confounding influences and to identify the independent effect of each socio-demographic factor. Notably, both in univariate- and multivariate analyses there was a consistent trend of public dental students showing less accurate knowledge about HIV and AIDS related issues than their private dental student counterparts. This reflects the existence of a social gradient among students attending different parts of the Sudanese educational system. Compared to public dental students, private students were mainly older, included lower proportions of women and higher proportions of subjects that were living outside Sudan indicating the higher socio-economic status needed to be able to attend privately funded and governed universities. As compared to students attending private institutions and having father's of high education, students from public dental institutions and those having father's with low education were less likely to be knowledgeable about modes of HIV transmission. Moreover, public dental students tended to be less likely to have received information from health workers and lectures and to be knowledgeable about risk groups. These differences might reflect variations in the HIV related attitudes and behaviors of the private- and public dental faculties as well as variation in the amount of material, lectures and number of clinical encounters regarding HIV and AIDS that are offered to students. The trend of younger students having less accurate knowledge than their older counterparts across HIV related issues corroborate previous findings among Pakistani medical students and suggests that students' knowledge level improves as they progress through their education programs [11].

The results of the present study should be interpreted with caution since it is limited by the use of self-administered questionnaires and not by interviews which are most commonly used in non-occidental settings and by the inclusion of students volunteering to participate. It might be argued, however, that anonymous self reports is more reliable than interview data in that the respondents are less prone to the pressures of social demand emanating from conversation face to face with a research assistant [30]. Moreover, the questions employed were sufficiently simple and unambiguous to achieve a reasonable degree of validity on the different variables. In fact previous researches have found such self- reports to be quite reliable.

The results of the present study revealed that Sudanese dental students have deficiencies with respect to their knowledge and amount of information received on HIV and AIDS related topics. This deficiency was more frequently observed in public dental students than in their private dental student counterparts. The results indicate that dental students in Sudan are less well prepared for their future task of treating patients with HIV infection and AIDS and highlight a need for improving the dental school curriculum regarding HIV and AIDS. Dental school based differences in terms of privately and publicly funded schools should be considered when planning improvements in the HIV and AIDS curriculum. Thus, the present findings might serve as a wake up call for dental program directors to explore further how well graduating students in the different institutions are prepared to treat patients at risk of or infected with HIV and AIDS. Dental students' interest in this topic, as revealed by their recognition of a need for further education reflects a susceptibility for change that should be both supportive and encouraging for dental educators in their efforts towards improving dental education on HIV and AIDS related topics in Sudan