According to the attribution theory, the problems of HIV stigma and discrimination can stem from both internal and external factors [23]. Our study supports this theory as we found that HIV knowledge and attitudes were determined by several external factors such as academic experience, interaction with key populations, and access to media; and these were on top of the internal factors such as beliefs and cultural background. This study is the first to report on HIV knowledge and attitudes among dietetic students in Indonesia. Our findings show that the level of HIV comprehension was low and stigmatized attitudes were high, which have been observed elsewhere among other health care students [17,18,19, 29].
Dietitians and dietetic students are often overlooked in the discussion about HIV despite their critical roles in HIV care and control. Training is mostly provided to doctors and nurses who are considered to have higher responsibilities in treatment and at the same time more vulnerable due to their frequent contact with the patients [30]. Even when it is provided, topics delivered during the training were also limited to the technical or clinical necessities and often missed the more fundamental aspect of building a good relationship between patients and providers [31]. The Indonesian National AIDS Commission highlighted the need to equip HIV training for health professionals with the principles of effective service delivery, anti-discriminatory behavior, and human rights [32].
Similar to the medical schools, all dietetic schools in Indonesia follow the national curriculum guideline [33]. The Indonesian Nutrition Science Collegium and The Indonesian Association of Nutrition Academic Institution developed a dietetic curriculum in Indonesia. The curriculum is designed according to an established set of standard professional competencies and should be followed by all dietetic schools in Indonesia. However, each university can develop electives and courses that reflect their academic mission, yet courses in HIV and AIDS are not mandatory. This gap explains our findings that although most participants have enrolled in a class that discussed HIV, their understanding of the topic remains low. When HIV becomes an optional topic in the curriculum, there is no guarantee that students would receive adequate information about HIV which neither builds the level of professional competency needed to treat the patients nor cultivates non-prejudice attitudes.
Of special concern, the regression analysis consistently presented that university affiliation was related to knowledge and attitude towards PLHIV. Comparative analysis also revealed that students from the private university scored lower than those from the state university in all types of tests. The apparent difference in the way dietetic schools teach HIV to their students triggers discussion of what is being taught in each institution and requires further investigation considering the scarcity in the literature on nutrition education in Indonesia. Some assumptions might be taken from the medical education system. Private medical schools are known to have less bureaucratic burdens and more liberty to adopt innovations in exchange for reduced governmental subsidies. However, the lack of government control is likely to hamper the quality of education as it has been reported that the newer and smaller private institutions are having trouble in establishing an appropriate quality assurance system and accreditation [33,34,35,36].
Enforcing all dietetic schools to follow the same set of regulations for curriculum implementation and quality assurance might be necessary to ensure students having similar academic experiences and developing the skills needed in the workforce. Educational innovation and experimentation must be reported and documented properly, thus, allowing replication and comparative analysis [34]. Our study suggests that to improve HIV knowledge and attitude, dietetic schools need to ensure that students have opportunities to interact with the patients or key populations, have access to accurate information sources and discuss HIV in a class setting with their peers and instructors. These findings correspond with previous studies, which indicated higher exposure to HIV information and key populations might improve awareness and acceptance of the individuals [12, 29, 37].
Creating a safe, secure, and supportive learning environment is important to encourage an open and honest discussion about HIV. As suggested in our study, in a conservative country like Indonesia where HIV discussion tends to attract controversy, understanding the interlinking of religion, culture, sexuality, and HIV is important. A study in Bangladesh proposed the need to provide training to the teachers in addition to efforts in improving the curriculum. Through training, teachers can develop confidence and skills in imparting HIV knowledge with greater sensitivity, and thus inspire more positive attitudes among students [38, 39].
We defined stigma in this study as any type of negative attitude and misconduct performed by health professionals towards PLHIV due to their HIV status. However, stigma is a multifaceted problem, not one rooted in a simple causality. The attribution theory lends credence to the explanation that the process of attributing stigma usually happens without the person’s awareness [40]. Considering the tenets of the attribution theory that underpin the attributes given to PLHIV: personal responsibility, controllability, perceived dangerousness, and familiarity, an effort beyond an instructional approach is much-needed. Additionally, behavioral studies found that HIV-related stigma is particularly fluid compared to other diseases. The perceived dangerousness, for example, is amenable to following swift advancement in treatment and control [24]. Therefore, several studies suggested the need to conduct multilayered intervention targeting factors at the individual, interpersonal, community, institution, and structural levels to reduce stigma [41, 42].
Finally, addressing the stigma towards PLHIV among health professionals is important to prevent further public health consequences. Stigma in health facilities disrupts patients-providers communication that might lead to distrust and poor adherence to medication. It might also deter patients from accessing proper care in a timely manner, counseling and testing services as well as other harm reduction interventions [13, 21, 43,44,45]. Reducing stigma matters because it also has the potential to open further academic discussion and debate.
Limitations
Several limitations should be taken into consideration in interpreting the results of this study. Firstly, the sample of dietetic students was selected conveniently from three universities only. Although these universities had wide coverage of student intake throughout Indonesia, which enables a culturally diverse study sample and might be typical of dietetic students in Indonesia, this assumption was not validated in the analysis. Nonetheless, the limited study setting might affect the external validity of the study and inferences must be made with caution to the study setting.
Secondly, the survey instruments might influence responses from the participants due to the use of standard Indonesian language and dialect, which may not address the discrepancies in language comprehension from participants who come from remote areas of Indonesia. As disparity in the quality of education is evident throughout Indonesia, students coming from marginalized areas might have trouble understanding the few jargons used in the questionnaire, despite our effort to use plain language. All this might explain the result of the reliability test of the instruments. Thirdly, considering the sensitivity of the issues, there is a risk of social desirability bias in the responses causing stigma to be underreported. However, the use of a self-administered questionnaire that gives more freedom and privacy to participants might minimize the problem. Finally, considering the nature of the cross-sectional study, our findings can only suggest an association with HIV knowledge and stigma.
