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Dental hygienists' beliefs, norms, attitudes, and intentions toward treating HIV/AIDS patients

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Title:
Dental hygienists' beliefs, norms, attitudes, and intentions toward treating HIV/AIDS patients
Physical Description:
Book
Language:
English
Creator:
Clark-Alexander, Barbara
Publisher:
University of South Florida
Place of Publication:
Tampa, Fla
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Subjects

Subjects / Keywords:
Human immunodeficiency virus
Acquired immune deficiency syndrome
Dental hygiene
Willingness to treat
Theory of reasoned action
Dissertations, Academic -- Community & Family Health -- Doctoral -- USF   ( lcsh )
Genre:
non-fiction   ( marcgt )

Notes

Summary:
ABSTRACT: There is a great demand and need for oral health care during the course of HIV disease (HIV Costs and Services Utilization Study; Marcus et. al., 2005). HIV+ patients identified three key barriers to obtaining oral health treatment: 1) beliefs and attitudes of dental health care providers (DHCPs) may have lead to their unwillingness to treat HIV/AIDS patients; 2) the existence of racial and ethnic disparities in health care in the United States, and 3) how DHCPs perceive their risk of contracting HIV. The fear and stigma associated with treating patients with HIV further compromises their access to care and their health status. Oral health conditions associated with HIV disease are frequently more severe than those of the general population, making access to both dental and medical care imperative. Plus, Florida has some of the highest numbers of HIV/AIDS patients in the nation.This study was descriptive, cross-sectional and used quantitative methods to explore the dental hygienists' behavioral and normative beliefs, attitudes, and intentions toward treating patients with HIV/AIDS. A three-phase pilot study was conducted to assess the validity and reliability of the survey instrument. An email delivery method was used to implement the survey, and a 22% response rate was achieved (n=219). The majority of respondents were female (96%), white (89%), married (77%), currently working (86%), and had treated HIV/AIDS patients in private practice (80%). Bivariate analysis showed that dental hygienists' intentions toward treating HIV/AIDS patients were significantly associated with five independent variables, and binary logistic regression confirmed the significance of two of these associations.Overall, study participants indicated that they were willing to, and had positive attitudes toward, clinically treating HIV/AIDS patients; they were confident in their ability to treat them, and their normative beliefs did not hinder their intention to do so, and they did not worry about acquiring HIV in the workplace. Three recommendations were made: increase access to oral health care for HIV/AIDS patients within community settings by removing barriers to care, incorporate cultural/sensitivity training in all dental/dental hygiene school curriculums, and mandate Florida HIV/AIDS continuing education requirements every biennium for dentists and dental hygienists.
Thesis:
Dissertation (Ph.D.)--University of South Florida, 2008.
Bibliography:
Includes bibliographical references.
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Mode of access: World Wide Web.
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System requirements: World Wide Web browser and PDF reader.
Statement of Responsibility:
by Barbara Clark-Alexander.
General Note:
Title from PDF of title page.
General Note:
Document formatted into pages; contains 239 pages.
General Note:
Includes vita.

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University of South Florida Library
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University of South Florida
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Resource Identifier:
aleph - 001994144
oclc - 317402874
usfldc doi - E14-SFE0002428
usfldc handle - e14.2428
System ID:
SFS0026745:00001


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Dental Hygienists' Beliefs, Norms, Attitudes, and Intentions Toward Treating HIV/AIDS Patients by Barbara Clark-Alexander A dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy Department of Community and Family Health College of Public Health University of South Florida Major Professor: Robert J. McDermott, Ph.D. Michael Knox, Ph.D. Philip Marty, Ph.D. Karen Perrin, Ph.D. Jay Wolfson, Dr.P.H. Date of Approval: March 28, 2008 Keywords: human immunodeficiency virus, acquired immune de ficiency syndrome, dental hygiene, willingness to trea t,, theory of reasoned action Copyright 2008, Barbara Clark-Alexander

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Dedication To the patients with HIV/AIDS who have been marginalized, and to the dental professionals who have been willing to treat them.

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Acknowledgements It was an honor to work with a brillia nt, dedicated and energetic faculty who served on my doctoral and dissertation comm ittees: Robert J. McDermott, Ph.D., my major professor, I appreciate your patience, kindness, direction and wisdom, and thank you for guiding me through this incredible journey that we began so many years ago. Jay Wolfson, Dr.P.H., thank you for your continued diligence in keeping me on the path, Karen (Kay) Perrin, Ph.D., Philip Marty, Ph.D., and Michael Knox, Ph.D., thank you for your guidance and encouragement during the many years that it has ta ken to develop and complete this research project. I wish to thank Peter Levin, Sc.D., and Jay Wolfson, Ph.D., for launching me into public health with vigor and enthusiasm, and for encouraging me to enroll in this program. I would like to express my gratitude to Hana Osman, Ph.D., David Hogeboom, M.S.P.H., Chris Hoelle, M.C.S.E., David Lewis, Ph.D.(c), Terri Singer, M.L.S., Mirtha Whaley, Ph.D., Beverly Sanchez, Michele Seb ti, Kay White and my co-workers Marylin, Barbara, Mary and Robin for your consistent help and support in getting me to this conclusion. Finally I would like to thank my friends (you know who you are) who walked the path with me, thank you for believing in me and for your uplifting and steadfast support and friendship. Without you, this would not have been possible.

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i Table of Contents List of Tables.......................................................................................................................v List of Figures...................................................................................................................vii Abstract....................................................................................................................... .....viii Chapter 1: Introduction....................................................................................................... 1 Statement of the Problem.........................................................................................3 Purpose of the Study................................................................................................8 Assumptions for the Study.......................................................................................8 Delimitations of the Study.......................................................................................9 Limitations of the Study...........................................................................................9 Definitions of Terms..............................................................................................10 Chapter 2: Review of the Literature..................................................................................19 Historical Overview of the Epidemic in the United States....................................19 Florida and HIV/AIDS...........................................................................................22 Racial and Ethnic Disparities in Health Care........................................................24 Elimination of Health Disparities..............................................................25 Race and Ethnicity.....................................................................................25 Income and Education................................................................................26 Poverty.......................................................................................................26 Disabilities.................................................................................................27 Healthy People 2010 ..............................................................................................28 Determinants of Health..........................................................................................29 Access to Quality Health Services.........................................................................31 Access to Oral Health Care....................................................................................34 Oral Health, At Risk Populations, and Oral Health Disparities.............................35 What it Means to be HIV+.....................................................................................37 The Dental/Dental Hygiene Profession.................................................................46 Ethical Practice in Dental Treatment.....................................................................47 Transmissibility of HIV/AIDS...............................................................................50 History of Infection Control Related to HIV/AIDS...................................50 Purported or Actual Cases of HIV Transmission from DHCPs to Patients.............................................................................................52 Preventing Transmission of Bl oodborne Pathogens: 2003...................................58 Risk........................................................................................................................60 DHCPs Perceptions of Risk......................................................................61 Other Health Care Providers Perception of Risk.......................................62

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ii Public Perceptions of Risk.........................................................................64 Transmissibility of HIV/AIDS to Pa tients and to Dental Health Care Professionals........................................................................................64 HIV/AIDS Continuing Educati on for Dental Personnel........................................67 Dentist........................................................................................................67 Dental Hygienist........................................................................................67 International Picture: Treatme nt of HIV/AIDS Patients.......................................68 What Justifies Me Doing This Now?.....................................................................71 Attitudes.................................................................................................................72 Intentions................................................................................................................76 Unwillingness/Refusal to Treat..............................................................................78 Behavior.................................................................................................................81 Dental Care Experiences of HIV+ Individuals......................................................81 Theoretical Framework..........................................................................................83 Summary................................................................................................................90 Chapter 3: Methods...........................................................................................................9 2 Purpose of the Study..............................................................................................92 Objectives of the Study..........................................................................................92 Research Questions................................................................................................93 Study Design..........................................................................................................93 Population and Sample..........................................................................................96 Sampling Bias........................................................................................................97 Levels of Permission..............................................................................................98 Protection of Human Subjects...................................................................98 Other Permissions......................................................................................98 Selection of Variables............................................................................................99 Dependent Scale.........................................................................................99 Independent Scales.....................................................................................99 Demographic / Independent.....................................................................100 Instrument............................................................................................................100 Intention / Willingne ss to Provide Care...................................................100 Perceived Self Efficacy / Clinical Ability................................................102 Dental Hygiene Care Concerns / Perceived Risk....................................102 Attitude / Normative Beliefs....................................................................104 Demographics..........................................................................................104 Power Analysis and Sample Size.........................................................................105 Pilot Study............................................................................................................106 Phase 1 of Pilot Testing: External Expert Panel Review........................107 Phase 2 of Pilot Tes ting: Mini-pilot Test................................................107 Phase 3 of Pilot Tes ting: Field Testing...................................................107 Reliability and Validity of Instrument.................................................................108 Internal Consistency Reliability...............................................................108 Survey Administration.........................................................................................112 Missing Data........................................................................................................114 Data Analysis.......................................................................................................115

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iii Descriptive Statistics / Non-Parametric Tests..........................................116 Regression Model....................................................................................118 Chapter 4: Results...........................................................................................................1 21 Description of Respondents.................................................................................121 Research Question 1: What are dental hyg ienists stated inte ntions, attitudes, perceived risk, perceived self efficacy and normative beliefs toward treating HIV/AIDS patients?..........................................................................124 Research Question 2: What is the association between dental hygienists intentions to treat and perceived self efficacy, perceived risk of being infected, attitudes and normative beli efs toward treating HIV/AIDS patients?.........................................................................................................127 Research Question 3: Is there an association between year s in practice, and intention to treat HIV/AIDS patients?...........................................................129 Research Question 4: Is there an association between ever treated an HIV+ patient as a student, and intention to treat HIV/AIDS patients?....................130 Research Question 5: Is there an association between ever treated an HIV+ patient in private practice, and inte ntion to treat HIV/AIDS patients?..........131 Research Question 6: Is there an as sociation between knowing a friend or family member with HIV/AIDS, and inte ntion to treat HIV/AIDS patients?.........................................................................................................133 Research Question 7: What is the m easure of association between dental hygienists intentions to tr eat, perceived self efficac y, perceived risk of being infected, and attitudes and norma tive beliefs about treating HIV/AIDS patients?.......................................................................................134 Block 1.................................................................................................................135 Block 2.................................................................................................................137 Regression Summary...........................................................................................138 Chapter 5: Discussion, Conc lusions and Recommendations..........................................139 Discussion of Results...........................................................................................140 Research Question 1: What are dental hyg ienists stated inte ntions, attitudes, perceived risk, perceived self efficacy and normative beliefs toward treating HIV/AIDS patients?..........................................................................140 Research Question 2: What is the associ ation between dental hygienists intentions to treat and perceived self efficacy, perceived risk of being infected, attitudes and normative beli efs toward treating HIV/AIDS patients?.........................................................................................................142 Research Question 3: Is there an association between year s in practice, and intention to treat HIV/AIDS patients?...........................................................142 Research Question 4: Is there an association between ever treated an HIV+ patient as a student, and intention to treat HIV/AIDS patients?....................143 Research Question 5: Is there an association between ever treated an HIV+ patient in private practice, and inte ntion to treat HIV/AIDS patients?..........143

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iv Research Question 6: Is there an as sociation between knowing a friend or family member with HIV/AIDS, and inte ntion to treat HIV/AIDS patients?.........................................................................................................144 Research Question 7: What is the m easure of association between dental hygienists intentions to tr eat, perceived self efficac y, perceived risk of being infected, and attitudes and norma tive beliefs about treating HIV/AIDS patients?.......................................................................................144 Recommendations................................................................................................145 Recommendation 1..............................................................................................145 Recommendation 2..............................................................................................146 Recommendation 3..............................................................................................148 Strengths of the Study..........................................................................................151 Weaknesses of Study...........................................................................................152 Implications for Public Health.............................................................................153 Implications for Future Research.........................................................................154 Afterthoughts.......................................................................................................156 Personals..............................................................................................................157 List of References............................................................................................................158 Appendices Appendix A: Permissions...................................................................................183 Appendix B: Expert Panel Survey......................................................................192 Appendix C: Timeline, FDHA Blast, Mail and Email Templates......................199 Appendix D: Letter of Consent / Survey............................................................205 Appendix E: IRB.................................................................................................211 Appendix F: Data Analysis Plan.........................................................................213 Appendix G: SCBOD / FTC Decision, Florida Legislation...............................216 Appendix H: ADHA Supervision / Direct Access Documents..........................221 Appendix I: Personal Communication...............................................................238 About the Author...................................................................................................End Page

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v List of Tables Table 2.1 Percent of Persons Living with AIDS: U.S. and Florida By Gender, Race & Mode of Transmission, 2003.....................................24 Table 3.1 Estimates of Cronbachs Alpha by Subscale...........................................111 Table 4.1 Demographic Characteristic s of Responding Dental Hygienists.............123 Table 4.2 Dental Hygienis ts Intentions to Treat HIV/AIDS Patients (INT Scale)........................................................................................................124 Table 4.3 Dental Hygienists Self-E fficacy for Treating HIV/AIDS Patients (SELF Scale)............................................................................................125 Table 4.4 Dental Hygienists Perceive d Risk in Treating HIV/AIDS Patients (RISK Scale)............................................................................................125 Table 4.5 Dental Hygienists Attit udes and Behavioral Beliefs toward Treating HIV/AIDS Patients (ATT Scale)...............................................126 Table 4.6 Dental Hygienists Normativ e Beliefs toward Treating HIV/AIDS Patients (NORM Scale)............................................................................127 Table 4.7 Univariate Analysis of Five Constructs Used to Assess Dental Hygienists Future In tentions to Treat HIV/AIDS Patients.....................128 Table 4.8 Intention Scale Scor es by Other Scale Scores.........................................129 Table 4.9 Association betw een Intention Scale Score and Dental Hygienists Years in Practice......................................................................................129 Table 4.10 Correlation of Intention S cale Scores with History of Having Treated HIV/AIDS Patients as a Student.................................................130 Table 4.11 Recoded Variable: Correlation of Intention Scale Scores with History of Having Treated HIV/AIDS Patients as a Student...................131 Table 4.12 Correlation between Intention Scale Scores and History of Having Treated HIV/AIDS Patients in Private Practice.......................................131

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vi Table 4.13 Pairwise Comparisons: Correla tion of Intention S cale Scores with History of Having Treated HIV/AIDS Patients in Private Practice.........132 Table 4.14 Recoded Variable: Correlation of Intention Scale Scores with History of Having Treated HIV/AIDS Patients in Private Practice.........133 Table 4.15 Correlation of In tention Scale Scores w ith Knowing a Friend or Family Member with HIV/AIDS.............................................................134 Table 4.16 Block 1: Logistic Regr ession Predicting De ntal Hygienists Intentions to Treat HIV/AIDS Patients....................................................137 Table 4.17 Summary of Logistic Regr ession Analyses Predicting Dental Hygienists Intentions to Treat HIV/AIDS Patients................................138

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vii List of Figures Figure 2.1 Determinants of Health..............................................................................30 Figure 2.2 Theory of Reasoned Action.......................................................................85 Figure 2.3 Factors Determining Ones Be havior and Survey Item Categories...........87 Figure 2.4 Theories of Reasoned Action / Planned Behavior.....................................88 Figure 3.1 Distribu tion of the Dependent Variable..................................................120

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viii Dental Hygienists Beliefs, No rms, Attitudes, and Intentions Toward Treating HIV/AIDS Patients Barbara Clark-Alexander ABSTRACT There is a great demand and need for oral health care during the course of HIV disease (HIV Costs and Services Utilization St udy; Marcus et. al., 2005 ). HIV+ patients identified three key barriers to obtaining oral health treatment: 1) beliefs and attitudes of dental health care providers (DHCPs) may have lead to their unwillingness to treat HIV/AIDS patients; 2) the existe nce of racial and ethnic dispar ities in health care in the United States, and 3) how DHCPs perceive their risk of contracting HIV. The fear and stigma associated with treating patients with HIV further compromises their access to care and their health status. Oral health conditions associated with HIV disease are frequently more severe than those of th e general population, making access to both dental and medical care imperative. Plus, Florid a has some of the highest numbers of HIV/AIDS patients in the nation. This study was descriptive, cross-sectional and used quantitative methods to explore the dental hygienists behavioral and normative beliefs attitudes, and intentions toward treating patients with HIV/AIDS. A three-phase pilot study was conducted to assess the validity and reliability of the survey instrument. An email delivery method was used to implement the survey, and a 22% response rate was achieved ( n=219). The

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ix majority of respondents were female (96%), white (89%), married (77%), currently working (86%), and had treated HIV/AIDS patients in private practice (80%). Bivariate analysis showed that dental hygienists in tentions toward treating HIV/AIDS patients were significantly associated with five i ndependent variables, and binary logistic regression confirmed the significance of tw o of these associations. Overall, study participants indicated that they were w illing to, and had positive attitudes toward, clinically treating HIV/AIDS patients; they we re confident in their ability to treat them, and their normative beliefs did not hinder their intention to do so, and they did not worry about acquiring HIV in the workplace. Three recommendations were made: increase access to oral health care for HIV/AIDS patients within community settings by removing barriers to care, incorporate cultural/sensitivity training in all dental/den tal hygiene school curriculums, and mandate Florida HIV/AIDS continuing education requirements every biennium for dentists and dental hygienists.

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1 Chapter One Introduction Consumers perceived unmet need for any he alth care service is a useful index of both potential demand and actual medical nee d. Historically, actual demand alone has served as the principal measure of need in community health model assessments. This historic perspective notwithstanding, the combination of clinically assessed need (independent of demand) and consumer perception of unmet need may get far closer to an objective basis for determining both the health status of communities and the need for health care professionals and services to care for particular populations more adequately. In the instance of high-risk populations, perceptions of unmet need can be especially valuable in helping to assess both health stat us and how and where to deploy health care resources. In the case of oral health, surprisingly little has been done in the external assessment (utilization) or internal assessment (perceived need) of relevant services. There has been a relative dearth of atten tion paid by health care planners and policy makers to dental health issues, despite the important relationships established among oral health, nutrition and general health. The perceived unmet need for oral health care is a useful measure of potential demand, because it represents whether people f eel their wants for dental services are

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2 being fulfilled. In the HIV Costs and Servi ces Utilization Study (H CSUS) of unmet need for oral health treatment in a nationally re presentative sample of HIV+ patients, an estimated 40% or 88,000 medical patients reported unmet need for oral health care during at least one of three interviews of the (Mar cus, Maida, Coulter, Freed, Der-Martirosian, Liu, Freed, Guzman-Becerra, & Andersen, 2005). The perceived unmet need for oral health care in this population is considerably higher than in the general U.S. population (11%; Positive Outcomes, Inc., 2006). There is a great demand and need for oral health care during the course of HIV disease, as it has been shown that physicians are not proficient in diagnosing changes in the oral cavity (Glick & Burris, 1997; Paauw, Wenrich, Curtis, Carline & Ramsey, 1995). Other health care providers, social and support networks rely on dental health care wo rkers to provide services within their area of expertise (Glick, 1996). Oral health conditions associated with HIV disease are frequently more severe than those of the general population, maki ng access to both dental and medical care imperative. A previous cross-sectional HCSUS study estimated that 33,000 people had unmet dental needs, and unmet dental needs were twice as prevalent as unmet medical needs (Heslin, Cunningham, Marcus, Coulter, Freed, Der-Martirosian, Bozzette, Shapiro, Morton, & Andersen, 2001). The dramatic incr ease in unmet need for dental services during those four years, speaks to the growi ng problem of lack of access to dental care for persons with HIV/AIDS. The significance of these studies (Marcus, et al, 2005; Heslin, et al, 2001) is evident when one considers the scarcity of dent al health care professi onals that have been willing to treat persons with HIV/AIDS ove r the last 25 years (Sadowsky & Kunzel,

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3 1994). In fact, the dental profession, particularly in the United States, has been unwilling to give clear and unmistakable answ ers to individual dentists questions about the care of HIV+ patients (Glick & Burris, 1997). Whereas the medical needs of patients with HIV/AIDS are important, unmet dental needs also may nega tively influence their health ((NIH/NIDCR, 2000; Zabos et al, 2002). Statement of the Problem In the past half-century, we have come to recognize that the mouth is a mirror of the body, it is a sentinel of disease, and it is critical to overa ll health and wellbeing. The challenge facing us todayto help all Americans achieve oral healthdemands the best efforts of pub lic and private agencies as well as individuals. We must bu ild public-private partnerships to provide opportunities for individuals, communities, and health professionals to work together to maintain and improve the nation's oral health. We also must build an effective health infrastructure that meets the or al health needs of all Americans and integrates oral health effectively into overall health. We must work to change perceptions about oral h ealth among the general public, among policymakers, and among health providers. We must remove the barriers between people and oral health services (NIH/NIDCR/U.S. Surgeon Gene ral 3.David Satcher, May 25, 2000, p.1). The first key barrier has been dental health care providers (DHCPs) whose attitudes may lead to their being unwilli ng to treat patients with HIV/AIDS. Consequently, persons with HIV/AIDS have presented the dental profession with a

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4 number of ethical challenges (Doyal, 1997). The life-th reatening consequences of HIV/AIDS, its infectious nature and the social stigma associated with the disease have led to a range of ethica l dilemmas for dental health prac titioners including whether or not to treat HIV-infected patients. Despite their training and education, many health care professionals are likely to share some of the same attitudes toward AIDS and HIV+ patients as the lay community (Dow & Knox, 1988). The Institute of Medicine (IOM) report, Access to Health Care in America (1993), noted findings from the Robert Wood Johnson Foundation AIDS Health Services Program and Evaluation Study. The comment repeated in each of the 15 communities studied was that only a handful of private phys icians were seeing the majority of persons with HIV disease, and that access to dent al care for persons with HIV infection was similarly constrained. Access to dental care is essential fo r all persons, particularly for ones with complex medical conditions (Glick & Burris, 1997). Therefore, dentists have a moral and professional obligation to provide care to all persons within the dentists realm of expertise. However, throughout the HIV/ AIDS epidemic, DHCPs have demonstrated an unwillingness to treat HIV-infected patients (Gerbert, Badner & Maguire, 1988; Sadowsky & Kunzel, 1994; Doyal, 1997; McCarthy, Koval & McDonald, 1999). The issue of access to health care is not new, and this snapshot of more than a decade ago has not changed. A synopsis of a situation in New Orleans, Louisiana was described in the CDC HIV/ST D/TB Prevention News Update (Pope, 2004) adapted from an article in the New Orleans Times-Picayune from March 17 of the same year. The article stated the concern that individual metropolitan areas would have in making decisions about how they used their HIV/AI DS funds since federal Ryan White funding

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5 had declined in New Orleans by more than $4 million during the last fiscal year. New Orleans was one of 40 U.S. cities that rece ived less money that year. Even prior to Hurricane Katrina disaster of 2005, the cuts m eant closure of the local hospital dental clinic that served more than 700 regional HI V patients. The city clinic and Louisiana State Universitys dental school clinic were alternatives for re ceiving care, but long waiting lists existed. The Ryan White CARE Act provides care and support to those with no or limited insurance, and is the payor of last resort for persons infected with HIV (The Kaiser Family Foundation, 2004). Many Ryan White CARE Act programs that pay for the unmet health needs of persons living with HIV disease have sustained federal funding reductions or have been level-funded for up to five years. Level funding translates into trying to provide the services to even more clients with the same amount of money that was awarded five years ago. The current crisis of federal and state funding of HIV/AIDS dental services, in selected Florida counties must be addressed. In 2004, the West Central Florida Ryan White CARE Council, a regional planning and governing group overseeing funding and provision of services for persons w ith HIV/AIDS, had only four contracted dentists in eight counties to pr ovide oral health services. When federal funding was reduced, dental funds were re -appropriated throughout service categories that reduced funds for dental servi ces (CARE Council budgetary handout, 2004, August 26). The bottom line translated into less ac cess to dental care. The picture has not changed, and two years later, four dentists continue to serve these eight counties. Additionally, an ad hoc dental advisory committee has been established to review new issues of access to dental care services.

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6 A second issue is the existence of racial a nd ethnic disparities in health care in the United States as documented in the Institute of Medicine report, Unequal Treatment (2002). A conclusion of this report was that provider bias and stereotypical beliefs may play a role in clinical decision-making, with respect to dental care, as members of minority groups are disproportionately affect ed by both occurrence of the disease and the access issues cited above. Those who suffer the worst oral health include poor Americans. . Members of racial and ethnic groups also experience a disproportionate leve l of oral health problems. And people with disabilities and complex health conditions are at greater risk for oral diseases that, in turn further complicate their health (NIH/NIDCR/U.S. Surgeon General David Satcher, May 25, 2000, p.2). Oral health providers can help in earl y diagnosis of HIV/AIDS, which can first show up as oral fungal, bact erial or viral infections a nd lesions (American Public Health Association, 2004). Regular dental exams by a dentist for people with HIV are important because people with compromised immune systems will generally have the first symptoms show up in their mouth (Heslin et al, 2001; The Henry J. Kaiser Family Foundation, 2001).

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7 Oral health problems associated with HIV are often more complicated and difficult to treat than those problems in the general populati on, and require the attention of both medical and dental personnel (Heslin et al, 2001). The third issue pertains to how DHCPs per ceive their risk of contracting HIV. Some staff members will experience anxiety and uncertainty when treating HIV-infected people, due in part to stig matizing beliefs and prejudices (Dow & Knox, 1988). The fear and stigma associated with treating patients with HIV further compromises their access to care, and thus, their health status. More than two decades into the worst healthcare crisis the world has ev er known, .. stigma still challenges efforts to prevent, to treat and, ultimately, to cure HIV/AI DS. Fortunately, stigma is something we have the ability to prevent, control and eradicate (Gra ham, 2005, Kaiser Family Foundation News Release, p.1). Moreover, HIV has come to be viewed as a chronic disease, rather than a terminal disease (Scandlyn, 2000). In 1989, the head of the National Cancer Institute, Samuel Broder, announced at the internationa l AIDS meeting in Montreal, Quebec, that AIDS was a chronic illness, and that the trea tment should follow the cancer model. This public statement shifted the social definition of AIDS from an acute to a chronic illness, a shift that came with economic and cultu ral repercussions for the treatment and understanding of AIDS (Scandlyn, 2000). Whereas the number of HIV-infected pers ons continues to incr ease in Florida and in the southern U. S. in general, the need grows for providing dental services to patients with faltering immune systems. As of J une 30, 2005, Florida ranked th ird in the nation in the total number of AIDS cases among adults and adolescents, and second for the number of HIV cases among adults and adolescents na tionally (Florida Department of Health,

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8 September, 2005). Because Florida is highl y impacted by HIV/AIDS, a logical question would seem to be why do persons with HIV/ AIDS in Florida have difficulty obtaining dental treatment? Purpose of the Study This study will examine the a ttitudes of currently licensed dental hygienists in Florida with respect to providing treatment to HIV-positive persons. Intentions to treat HIV-positive patients will be explored, as intention is an indicator of probable behavior. Dental health care professionals awarene ss of access to dental care by HIV/AIDS patients has been an ongoing issue. Better da ta of this type may improve understanding of, and may increase access to, oral h ealth care for the HIV-positive population. Assumptions for the Study This study contains the following assumptions: Instruments chosen to measure attitude s, behavioral and normative beliefs, intention to treat, and be haviors are appropriate; Instruments to measure attitudes, behavi oral and normative beliefs, intention to treat, and behaviors will validly assess the constructs; Persons to whom the surveys are addressed are the individuals who fill them out; Respondents to the survey instruments complete them honestly, and to the best of their ability.

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9 Delimitations of the Study Delimitations are within the researchers control. For example, only dental hygienists with active licens es in Florida who are memb ers of the Florida Dental Hygienists Association will be included in the study. Pa rticipation in the study is voluntary. The study is also delimited to the specific universe of questions and items contained in the survey instrument to meas ure paradigms, values and behaviors. Limitations of the Study Limitations are not under the researche rs control. This study has several limitations. First, the data used are cross-sec tional, and therefore, may not be transferable to other settings and times. Second, study fi ndings may be tempered by the validity of the self-reported measures. Although the assessment survey was designed to enhance validity, the actual vali dity of the responses is unknow n, particularly when questions pertain to sensitive issues such as treating patients with HIV and AIDS in dental practice. Social desirability response bias occurs wh en a subject reports in a socially desirable manner, rather than reporting the information truthfully (McDermott & Sarvela, 1999). The third issue is generalizability of the study. Persons surveyed may not be representative of all dental hygienists in Florida, and furt hermore, dental hygienists in Florida may not be representative of dental hygienists nationally or internationally. Dental hygienists in Florida who are member s of professional dental associations may differ from dental hygienists who are not members of these organizations. Moreover, persons who answer surveys, may be differe nt from persons who choose not to answer them. The final issue is one of the practice status of dental hygienists in Florida. By law,

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10 dental hygienists are ruled by the Florid a Board of Dentistry, and do not have a regulatory board of their own. This limits their ability to choose to treat patients independently of the dentist. Definitions of Terms Acute Illness: characterized by sudden onset, obvious signs and symptoms, with some limitation of normal functioning; treatmen t is supportive or curative, duration consists of days or weeks and follows a predictable course (Scandlyn, 2000). AIDS: Acquired Immune Deficiency Syndrome. Most scientists think that HIV causes AIDS by directly inducing the death of CD4+ T cells or interfering with their normal function, and by triggering other ev ents that weaken a person's immune function. People with AIDS of ten suffer infections of the lungs, intestinal tract, brain, eyes and other organs, as well as debilitating weight loss, diarrhea, neurologic conditions and can cers such as Kaposi's sarcoma and certain types of lymphomas (National Institutes of Healt h, U.S. Department of Health & Human Services, National Institute of Allergy and Infectious Diseases, 2001). American Dental Hygienists Association (ADHA): the largest national organization representing the professiona l interests of the more th an 120,000 dental hygienists in the United States of America. Attitude: the tendency to react positively or ne gatively to a person, object or situation; as a learned predisposition to respond in a consistently favorable or unfavorable manner with respect to a given object (Fishbein, & Ajzen, 1975).

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11 Barriers: component of the Health Belie f Model (HBM); an individuals perceived barriers to successfully performing a health behavior. Behavioral Intention: perceived likelihood of performing the behavior. Benefits: component of the Health Belie f Model (HBM); an individuals perceived benefits of successfully pe rforming a health behavior. Chronic Illness: may arise from an acute epis ode that does not resolv e itself. Course of illness is uncertain and unlimited in time, mostly characterized by periods of acute crisis and remission; treatment is direct ed at relieving symptoms and slowing degeneration, not effect ing cure (Scandlyn, 2000). Culture: an integrated pattern of hum an behavior includi ng thought, communication, ways of interacting, roles and relation ships, and expected behavior, beliefs, values, practices, and customs (Den boba, Bragdon, Epstei n, Garthright, & Goldman, 1998). Cultural Competence: an individuals and programs ability to honor and respect those beliefs, interpersonal styles, attitudes, and behaviors both of families who are clients and the multicultural staff providing services (Denboba, et al, 1998). Cultural Diversity: differences that pe ople present and the knowledge about such differences (Denboba, et al, 1998). Dental Health Care Providers (DHCPs): all paid and unpaid pe rsonnel in the dental health-care setting who may be occupationally exposed to infectious materials. Besides those persons working in direct patient care, other persons not directly involved in patient care such as ad ministrative, clerical, housekeeping, maintenance or volunteer personnel may also be potentially exposed to infectious

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12 agents that may include body substances contaminated supplies, equipment, environmental surfaces, water or air. Dental Hygiene: the rendering of educational, preventive, and therapeutic dental services pursuant to Florida Statutes 466.023 and 466.024, and any related extra-oral procedure required in the performance of such services. Dental Hygienist: a licensed dental professional who works under the direct or indirect supervision of a licensed dentist to examine and clean the teeth and oral structures, and teach preventive oral hea lth to patients; preventive oral health professionals, licensed in dental hygiene, who provide educati onal, clinical and therapeutic services that support total health through the promotion of optimal oral health. Dentist: a person who is skilled in and licen sed to practice the prev ention, diagnosis, and treatment of diseases, injuries, and malf ormations of the teeth, jaws, and mouth. Dentistry: the healing art which is concer ned with the examinati on, diagnosis, treatment planning, and care of conditions within the human oral cavity and its adjacent tissues and structures. It includes the performance or attempted performance of any dental operation, or oral or oral-maxillofacial surgery and any procedures adjunct thereto, including physical evaluati on directly related to such operation or surgery pursuant to hospital rules and regulations. It al so includes dental service of any kind gratuitously or for any remuneration paid, or to be paid, directly or indirectly, to any person or agency. Direct Access: dental hygien ist can initiate treatment ba sed on their own evaluation of the patients needs and without the specifi c authorization of a dentist, treat the

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13 patient without the presence of a dentis t, and can maintain a provider-patient relationship (American Dental Hygienists Association, 2007). Discrimination: the unfair and unjust treatment of an individual based on his/her real or perceived HIV status (Sta te of Florida, Florida Statutes 466.003, 2004; UNAIDS, 2004, January 16; UNAIDS, 2003). Duty: an action which others must perform in order to satisfy individual claims. Effect Size: the degree to which the null hypothe sis is false (the size of the effect of an independent variable on the depende nt variable; Munro, 2005). Florida Dental Association (FDA): a profe ssional organization representing dentists licensed in the state of Florida. Florida Dental Hygienists Association (F DHA): a branch of the American Dental Hygienists Association that advocates for dental hygienists practicing dental hygiene in Florida. Health Disparity: an inequali ty or gap that exists between two or more groups. Health disparities are believed to be the result of the complex interaction of personal, societal, and environmental factors; the diminished h ealth status of population subgroups defined by demographic factors su ch as age and socioeconomic status (SES), geography, disability stat us, and behavioral lifestyles (National Institutes of Health, U.S. Department of Health & Human Services, National Institute of Dental and Craniofacial Research, 2002). HIV: Human Immunodeficiency Virus. HIV belongs to a subgroup of retroviruses known as lentiviruses, or "slow" viruses. The course of infection with these viruses is characterized by a long interval between init ial infection and the onset

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14 of serious symptoms. HIV disease is char acterized by a gradual deterioration of immune function where crucial immune cel ls called CD4+ T cells are disabled and killed during the typical course of infection. Th ese cells, sometimes called "T-helper cells," play a cent ral role in the immune re sponse, signaling other cells in the immune system to pe rform their special functions. During HIV infection, the number of these cells in a person's blood progressively declines. When a person's CD4+ T cell count falls below 200/ mm3, he or she becomes particularly vulnerable to the opportunistic infections and cancers that ty pify AIDS, the end stage of HIV (National Institutes of Hea lth, U.S. Department of Health & Human Services, National Institute of Allergy and Infectious Diseases, 2004). Hypothesis: a prediction about the nature of the relationship between two or more variables (Mark, 1996). Intention: a persons purpos e, goal, aim or objective. Internet access: Using a computer to acce ss the World Wide Web via a search engine. Kurtosis: a measure of whether the curve is normal, flat, or peaked. Market Justice: individuals are responsible for their own he alth. Personal responsibility is the basis for distributing burdens and benefits, and people are responsible for their own actions. Few exp ectations exist that societ y should act to protect or promote the health of its members. Missingness: the condition referred to when missing data results during data collection (Buhi, Goodson, & Neilands, 2008). Model: a framework or system for organizi ng concepts into a meaningful schema; a conceptual model is a paradigm (Taber, 2001). Models are often thought of as

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15 illustrations of paradigms, as they rela te the concepts and theories to form paradigms. Normative Beliefs: The beliefs underlying a persons subjective norm are called normative beliefs Normative beliefs are the persons beliefs that specific individuals or groups think he/she should or should not perform the behavior. Thus, the subjective norm may exert pressure to perform or to not perform a given behavior, independent of the persons ow n attitude toward the behavior. Occupational Exposure: Skin, eye, mucous me mbrane or parenteral contact with blood or other potentially infectious materials that may result from performing jobrelated duties. Paradigm: an example that serves as a model; a conceptual model (Taber, 2001). A paradigm is a basic structure and framewor k that can form the basis for a way of thinking (belief system or philosophy). Percentile: describes th e position of a score. Perceived behavioral control: a measure of perceived control over the behavior; concept similar to self-efficacy (Coreil, Bryant & Henderson, 2001). Power: the probability of detecting a differe nce or relationship if such a difference or relationship really exists; the likelihood of rejecting the null hypothesis (avoids a Type II error; Munro, 2005). Probability value (p value): the likelihood of obtaining the value of the statistic by chance alone, when conducting a statistical hypothesis test. Right: a claim that is socially accepted that an individual is entitled to make in a specific circumstance.

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16 Risk: The possibility of suffering harm or loss; danger. To expose to a chance of loss or damage; hazard. Self-efficacy: a persons judgment about their own ability to perform a task or goal successfully. Severity: component of the Health Belief Model (HBM); an individuals perception of the severity of a disease. Significance Level (alpha): probability of rejecting a true null hypothesis (making a Type I error; Munro, 2005). Skewness: a measure of the shape of an asymmetrical distribution. Social Justice: argues that public health is a public matter an d health outcomes reflect the decisions that a society makes for its citizen s. There is fairness in the distribution of benefits and burdens throughout society. Standard Precautions: Integrate and expand th e elements of universal precautions in the standard of care designed to protect DHCPs and patients from pathogens that can be spread by blood or any other body flui d, excretion, or secretion. These apply to contact with blood, all body fluids, secr etions, and excretio ns (except sweat), regardless of whether they contain blood, non-intact skin and mucous membranes. State Licensure: A process of written and skill-based testing to allow a person to practice dentistry or dental hygiene in a state. Stigma: The prick or mark of a pointed instrument, a spot, mark; a mark made with a burning iron; a brand; any mark of infa my or disgrace; sign of moral blemish; stain or reproach caused by dishonorable c onduct; reproachful characterization; a mark or blemish upon someone or something (UNAIDS, 2004 November 11);

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17 a process of devaluation of people either living with or associated with HIV/AIDS (UNAIDS, 2004 January 16) Subjective Norm: ones belief about whethe r most people approve or disapprove of the behavior. Summative Rating Scale: a group of items that are approximately equa l on attitude value where subjects respond in terms of agreem ent or disagreement. The Likert scale is a type of summative rating sc ale (McDermott & Sarvela, 1999). SupervisionDirect: supervision where by a dentist diagnoses the condition to be treated, a dentist authorizes the procedur e to be performed, a dentist remains on the premises while the procedures are pe rformed, and a dentist approves the work performed before dismissal of the patient. SupervisionIndirect: supervision whereby a dentist authorizes the procedure and a dentist is on the premises while the procedures are performed. SupervisionGeneral: supervision whereby a dentist authorizes the procedures which are being carried out but need not be present when the authorized procedures are being performed. The authorized procedur es may also be performed at a place other than the dentist's usual place of practice. The issuance of a written work authorization to a commercial dental laboratory by a dentist does not constitute general supervision (State of Florida, Florida Statutes 466.003, 2004; ADHA, 2007). Susceptibility: component of the Health Belief Model (HBM); an individuals assessment of their susceptibility to the disease.

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18 Universal Precautions: Based on the concep t that all blood and body fluids may be contaminated with blood and should be treated as infectious substances (CDC, MMWR, 2003, 52, No. RR-17). Vulnerable Populations: Social groups who a) have an increa sed susceptibility or higher than national average risk for health -related problems, and b) experience differential patterns of morbidity, mortal ity, and life expectancy as a result of fewer resources and exposure to risks (Dyer, 2003).

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19 Chapter Two Review of the Literature To understand the background for studying dent al hygienists in Florida, relevant literature is presented in the areas of the history of the HIV/AIDS epidemic in the United States and Florida, oral healt h, at risk populations and oral he alth disparities, the current state of the field of dentistry/dental hygiene including laws and regulations, and attitudes, intentions and behaviors toward treating patients with HIV/AIDS. Factors for not treating HIV/AIDS patients also will be explored. Historical Overview of the Epidemic in the United States On June 5, 1981, the Centers for Disease Control and Prevention (CDC) issued the first warning about a rare form of pneumonia (pneumocystis carinii ) among gay men (ages 29-36 years) in Los Angeles, a conditi on later found to be re lated to AIDS (CDC, MMWR, 1981 June 5). Then on July 4, 1981, the CDC reported that 26 homosexual men (20 in New York City, and 6 in California) had been diagnosed with Kaposis sarcoma, an uncommon malignancy in the United Stat es (CDC, MMWR, 1981 July 4). Following up on the cases of Kaposis sarcoma, the CDC reported in Morbidity and Mortality Weekly Report (MMWR) on August 28, 1981, that 15 more homosexual men had been diagnosed with pneumocystis carinii pneumonia (PCP), and an additional 70 more cases had been reported to the CDC with both of th ese conditions. The majority of these cases

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20 occurred in white men who were 25 to 49 years of age. Before June 5, 1981, Kaposis sarcoma had been seen only in elderly white men of Mediterranean origin. AIDS incidence in the United States incr eased rapidly during the 1980s, peaked in the early 1990s, and then declined. The reas on for this peak of new diagnoses was the expansion of the AIDS surveillance case de finition in 1993 that recognized associated clinical conditions in women. By 1996, reported AIDS incidence and deaths declined due to the advent of highly active antiretroviral therapies (HAART), and AIDS incidence and deaths finally leveled off by 2000. AI DS prevalence, however, continued to increase, and by the end of 2003, an estimated 405,926 persons in the U.S. were living with AIDS (CDC/HIV/AIDS Surve illance Report, 2003, Vol. 15). In the early 1980s, nearly all AIDS case s were diagnosed in males, but by 2003, only 73% of all AIDS cases and 70% of a ll HIV cases were diagnosed in adult and adolescent males (CDC/HIV/AIDS Surveillan ce Report, 2003, Vol. 15). During the same time period, cases among black males and females increased steadily, and by 1996, more cases occurred among blacks than any other racial/ethnic population. In 2003, 49% of all new AIDS cases and 50% of all new HIV cases in the U.S. were diagnosed in blacks (CDC/HIV/AIDS Surveill ance Report, 2003, Vol. 15). A steady increase in HIV-infection and developing AIDS cases has occurred among women since 1985. The number of women with AIDS in the U.S. rose from 7% in 1985 to 31% in 2003. Minority women in Am erica are disproporti onately affected by AIDS. Of the adult and a dolescent AIDS cases reporte d in women in 2003, 63% were among blacks and 18% were among Hispanics.

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21 The most common mode of exposure am ong persons reported with AIDS has been male-to-male sex, followed by injec tion drug use and heterosexual contact (CDC/HIV/AIDS Surveillance Report, 2005, Vol. 16). AIDS incidence increased rapidly in all of these risk categor ies through the mid-1990s (CDC/HIV/AIDS Surveillance Report, 2005, Vol. 16). From 2000 through 2004, the estimated number of AIDS cases increased among MSM, and also increased among persons exposed via heterosexual contact (CDC/HIV/AIDS Surveillance Report, 2005, Vol. 16). These two transmission categories accounted for 80% of all HIV/AIDS cases that were diagnosed in 2004. In the United States, approximately half of the 40,000 new HIV infections annually are among African-Americans; and the proportion of total HIV cases among women is increasing faster in the U.S. than in any other country CDC/HIV/AIDS Surveillance Report, 2003, Vol. 15). In fact, U.S. women accounted for 30% of the total number of HIV cases nationally through 2004 (CDC/HIV/AIDS Su rveillance Report, 2003, Vol. 15). Proportionally, more cases of AIDS are located in the South (Alabama, Arkansas, Delaware, District of Columbia Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahom a, South Carolina, Tennessee, Texas, Virginia, and West Virginia) as compared to the Northeast, West, and Midwest (Florida AIDS Action, 2002; The Henry J. Kaiser Fa mily Foundation, 2004). By the end of 1998, the profile of newly reported AIDS cases among women looked like this: 44% were in the South, 61% were among black women, and 38% had been transmitted heterosexually (Florida AIDS Action, 2002; Hader, Smit h, Moore, & Holmberg, 2001; UNAIDS, 2004; The Henry J. Kaiser Family Foundation, 2004).

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22 From 1981 through 2003, there were 929,985 AI DS cases reported in the United States, of which 337,409 (36%) cases were located in the So uth (CDC/HIV/AIDS Surveillance Report, 2005, Vol. 16). In addition, 221,065 cumulative HIV cases had been reported during the sa me period. HIV case reporting was initially legislated in three states (Colorado, Minnesota, and Wisconsin) in 1985 and has since grown to 37 states and 4 U.S. territories that are reporting HI V cases. Five million new HIV cases were reported worldwide in 2003, the most cases reported in any single year since the epidemic began (Kaiser Daily Reports, 2004, July 9). Florida and HIV/AIDS Whereas Floridas image is one of paradi se, it is not paradise for the growing number of residents who suffer from poverty, health problems and a lack of access to health care and social services According to the Florida Department of Health (FDOH), a major five-year goal is to treat infectious diseases of public h ealth significance (Dyer, 2003). One infectious disease, HIV/AIDS, is among the states top 10 causes of death. From 1981to 2003, Florida ranked third in the nation in the total number of reported adult and adolescent AIDS cases with 94,725 (The Henry J. Kaiser Family Foundation, December, 2004). The HIV statistics are even more staggering with Florida ranking second behind New York for confiden tial name-based HIV infection reporting for all ages (27,913). The startling issue here is that Florida has had confidential namebased HIV infection reporting only for new diagnoses since July 1997. Florida has followed the same racial and population profile s as the nation with one exception. The

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23 exception is that the percentage of women diagnosed with HI V/AIDS in Florida is higher than for the U.S. as a whole (Flo rida Department of Health, 2005). In 1994, women accounted for 22% of reported AIDS cases in the U.S. (CDC/HIV/AIDS Surveillance Report, 2003, Vol. 15). By 2004, that figure rose to 30% (CDC/HIV/AIDS Surveillance Report, 2005, Vol. 16). Of the AIDS cases diagnosed among Florida women reported through 2003, 72% were black, 17% were white, and 10% were Hispanic. An almost identical picture existed for Florida women with HIV where 72% were black, 16% were white, and 11 % were Hispanic (Florida Department of Health, 2003). The number of women in Florida diag nosed with AIDS through 2003 exposed through heterosexual contact increased to 52%, whereas 24% were injection drug users. The profile for women in Florida with HIV during the same period was similar with 53% reporting heterosexual contact, and 11% reporting injection dr ug use. HIV infection was the third leading cause of death among wome n ages 25 to 44 years in Florida, and the leading cause of death among black women in this age group (Florida Department of Health, 2005). The number of perinatally acquired AIDS cases peaked in the U.S. in 1992 (952), and has continued to decline in 2003 (59). The number of HIV/AIDS cases in infants and children is identical for the U.S. and Florid a remaining at 1% of the total number of perinatally acquired cases (Florida Department of Health, 2005). The picture of HIV/AIDS epidemiology in Florida is grim with a growing number of minorities contracting HIV. Therefore, it is critical to examine what underlies this growing trend.

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24 Table 2.1 Percent of Persons Living with AIDS: U.S. and Florida by Gender, Race & Mode of Transmission, 2003* Subgroup U.S. N=403,928 Florida N=42,861 Male 78% 73% Female 22% 27% White 36% 35% Black 42% 48% Hispanic 20% 16% Other 2% <1% MSM 46% 43% IDU 25% 16% MSM/IDU 6% 5% Heterosexual 22% 36% Other 2% 1% *Source: CDC, HIV/AIDS Surveillance Report, 2005; Vol. 16; data as of 12/31/03. FL = 10.6% of total number of persons living with AIDS in the U.S. Racial and Ethnic Disparities in Health Care An issue brief from the Kaiser Family Foundation (March, 2005), stated that racial and ethnic disparities in health care su ch as insurance covera ge, access, or quality of care, are among the many factors producing ine qualities in health status in the U.S. today. Health disparities began with the cont entious history of race relations in America, and continued with unequal and separate laws enacted by the government. Until the mid1960s, racial separatism was promoted by sepa rate bathrooms and water fountains for blacks and whites. Poverty among minorities kept young people out of school, and college, so there were few culturally similar h ealth care providers for African Americans. The enactment of Medicaid and Medicare in 1965, along with the enforcement of the 1964 Civil Rights Act, made an enormous diff erence in reducing the health care division

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25 in the U.S. But African Americans again lo st trust both in the government and in the health care system in 1972, when the Tuskegee Study was revealed. Elimination of Health Disparities Whereas closing the gap of health disp arities among minority populations is an arduous task, it has been targeted by Healthy People 2010 as a major goal. The second goal of Healthy People 2010 is to eliminate health dispar ities including di fferences that occur by gender, race or ethnicity, education or income, disability, geographic location, or sexual orientation. The momentum to addr ess health care disparit ies grew largely in response to the step taken by the U.S. De partment of Health and Human Services (USDHHS) in 1999 when it established a nationa l goal to eliminate h ealth disparities by the end of this decade. The ways in whic h health disparities can occur among various demographic groups in the United States are highlighted below. Race and Ethnicity Current information about the biologic and genetic characte ristics of African Americans, Hispanics, American Indians, Al aska Natives, Asians, Native Hawaiians, and Pacific Islanders does not explain the health disparities experienced by these groups compared with the white, non-Hispanic populati on in the United States. These disparities are believed to result from the comple x interaction among genetic variations, environmental factors, and specific health beha viors. For example, the death rate from HIV/AIDS for African Americans is more th an seven times that for whites (USDHHS, 2000).

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26 Income and Education Dissimilarities in income and education underlie many of the health disparities in the United States. Income and education are fundamentally related and often serve as proxy measures for each other In general, population grou ps that have the highest poverty rates and the least education also expe rience the worst health status. Disparities in income and education levels are associated with differences in th e occurrence of illness and death that include heart diseas e, diabetes, obesity, HIV/ AIDS, elevated blood lead level, and low birth weight (USDHHS, 2000). Higher levels of education also may increase ones likelihood of obtaining or understanding health -related information needed to develop health-promoting beha viors and beliefs in prevention. Higher incomes allow for increased access to medical care, enable people to afford better housing and live in safer neighborhoods, and increase the opportu nity to engage in health-promoting behaviors. The percentage of people in the lowest income families report that limitation in activity caused by chronic disease is three times that of people in the highest income families (USDHHS, 2000). Poverty There are distinct demographic differenc es in poverty by race, ethnicity, and household composition as well as geographical variations in poverty across the United States. The South has the highest rates of povert y in the nation (Collaborative Solutions, Inc., 2005). According to the Center for Di sease Control and Prevention, the South also has more estimated living AIDS cases and more AIDS-related deaths than any other region in the country (Collaborative Soluti ons, Inc., 2005). Whereas African Americans comprised only 19% of the Souths popul ation through 2003, 61% of the new AIDS

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27 cases in the South were among African Americ ans. This disproportionate infection rate combined with the Souths high rates of ot her sexually transmitted diseases, and the highest proportion of non-urba n dwellers combine for a ma jor public health challenge (Collaborative Solutions, Inc., 2005). Disabilities People with disabilities are identified as persons havi ng an activity limitation, who use assistance, or who perceive themse lves as having a disability. People with disabilities tend to repo rt more anxiety, pain, sleeplessn ess, and days of depression and fewer days of vitality than do people without activity limitations. People with disabilities also have other disparities, including lower rates of physical activity and higher rates of obesity (Collaborative Solutions Inc., 2005). Many people with disabilities also may lack access to health services, and medical and de ntal care (Collaborative Solutions, Inc., 2005). Whereas reducing health disparities through practice and research has been a major priority of the National Institutes of Health (NIH) for several years, progress toward this goal has been less than optim al. Mann (1998) believed that the primary contributors to health disparities were lack of resources, discrimination, and violation of human rights. Moreover, economic status, discrimination, diverse cultural backgrounds, and access to care have not always been present in existing plans and strategies to reduce health disparities (Flaskerud, 1998). In 1998, President Clinton made a national commitment to eliminate health disparities between racial a nd ethnic groups by 2010 in si x areas, one of which is

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28 HIV/AIDS. When Healthy People 2010 was published, this paradigm shift became official policy. Healthy People 2010 Healthy People 2010 goals are firmly committed to the principle that every person in every community across the nation deserves equal access to comprehensive, culturally competent, community-based health care syst ems that serve the needs of the individual and the community. It provides a framework for prevention for the United States (USDHHS, 2000). It is a stat ement of national health obje ctives that is designed to identify the most significant and preventable threats to peoples health, and to establish national goals to reduce these threats. Leading Health Indicators (LHI s) are being used to measure the nations health over this decade, a nd to reflect the major health concerns in the United States at the beginning of the 21st century. These ten LHIs were selected based on their ability to motivate action, and th eir importance as public health issues. Achieving health equity is one of two goals of Healthy People 2010 The greatest opportunities for eliminating hea lth disparities lie in empow ering individuals to make informed health care decisions, and in pr omoting community-wide safety, education, and access to health care. One of these LHIs (number 10) is Access to Health Care and applies to this dissertation. In addition, Healthy People 2010 provides a set of measurable oral health objectives that are part of th e overall set of national health objectives. These objectives and their benchmark statistics allow asse ssment of progress and improvement toward reaching the above goals. Three of the 28 focus areas of Healthy People 2010 apply to

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29 this body of work: focus areas 1 (Access to Quality Health Servic es), 13 (HIV), and 21 (Oral Health). Applicable objectives are listed below for each focus area. Focus Area 1 : Access to Quality Health Services Goal: Improve access to comprehensive, high-quality health care services. Objective Number and Short Title Primary Care: 1-4 Source of ongoing care 1-5 Usual primary care provider 1-6 Difficulties or delays in obtaining needed health care 1-7 Core competencies in health provider training 1-8 Racial and ethnic represen tation in health professions Focus Area 13 : HIV Goal: Prevent HIV infection and its related illness and death 13-13 Treatment according to guidelines Focus Area 21 : Oral Health Goal: Prevent and control oral and craniof acial diseases, conditions, and injuries and improve 21-10 Use of oral health care system Determinants of Health The determinants of health (individua l biology and behavior, physical and social environments, policies and interventions, a nd access to quality health care) have a profound effect on the health of individuals, communities, and the nation. For example, environmental factors and indi vidual behaviors are respons ible for about 70% of all premature deaths in the United States. Individual biology and behaviors influence health interacting with each other and with the individuals physical and social environments Additionally policies and interventions can improve health by targ eting factors related to individuals and their en vironments, including access to quality health care (see Figure 2.1). When policies are developed and preventi ve interventions are implemented that

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30 address the determinants of health effec tively, the burden of i llness can be reduced, quality of life can be enhanced, and longevity can be increased. Individual and community health depends greatly on access to quality health care. Expanding access to quality health care is important to eliminate health disparities and to increase the quality and years of h ealthy life for all Americans. Health care broadly includes services rece ived through health care provide rs, and health information and services received through other community venues. Figure 2.1 Determinants of Health Source: USDHHS, 2000. Healthy People 2010: Understanding and Improving Health 2nd ed. p.18.

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31 Access to Quality Health Services Attention to racial and ethnic differences in health status and access to care have increased markedly during the last decade (Kaiser Family Foundation, 2004). Notable differences in health status between white women and women of color, particularly African American women include: Women of color are more likely to report that they are in fair or poor health; African American women are more likely to have a physical condition that limits routine activities such as participating in work or school, and Latina women are less likely to report a chronic condition in need of ongoing care. Compared to whites, race and ethnicity are factors in womens chronic disease status: African Americans have twice the rate of hypertension for women ages 45-64; African American women have significan tly more arthritis than Latinas and whites; Both African American and Latina wome n have higher prevalence of diabetes; African American women are more likely to have HIV/AIDS; Latinas report problems in obtaining child care that results in delayed or unmet health care; Difficulties in finding time, or taking time off work was experienced by onequarter of women in all r acial and ethnic subgroups; Depression and anxiety are experienced pretty equally among racial and ethnic subgroups.

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32 Cultural competence is inextricably tied to quality of care and is a cross-cutting issue that affects all service delivery system s and providers. Providers must be aware of their own cultural values and be liefs and recognize how they influence their attitudes and behaviors. The meaning of cultural competence goes beyond cultural sensitivity to a level where this sensitivity is integrat ed into the planning, implementation, and evaluation of service systems and encompasses cultural diversity (Denboba, 1998). Reducing disparities in health care will requi re an emphasis on assuring access to both culturally and technically competent care (The Henry J. Kaiser Family Foundation, 2005). Financial, structural, and personal ba rriers can limit access to health care. Financial barriers include lack of health insurance, lack of enough health insurance to cover needed services, or lack of finances to cover services outside a health plan or insurance program. Structural barrie rs include not having primary care providers, medical specialists, or other health care professionals to meet special needs, or the lack of health care facilities. Personal barri ers include cultural or spir itual differences, language barriers, not knowing what to do or when to s eek care, or concerns about confidentiality or discrimination (USDHHS, 2000). There is increasing evidence that the underl ying racial and ethnic disparities in health care extend beyond any logi stic and economic factors. In a large-scale analysis of racial and ethnic inequities, the Institute of Medicine (2002) c oncluded that evidence suggested that bias, prejudice, and stereotypical beliefs on the part of healthcare providers may contribute to the differences in care. To curb these disparities, greater efforts must be made to increase the number of African American and Latino health care providers

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33 involved in HIV/AIDS treatme nt and research (Smith, Or gain, & Scott, 2004). More clinicians of color may also help to m itigate the lingering mistrust of the medical community among African Americans. Clinicia ns of other cultures must also learn to deliver culturally competent care in an envir onment that is safe and comfortable. Culture influences: (1) how health, il lness and disability are per ceived; (2) attitudes toward health care providers, facilities, and how he alth information is communicated; (3) help seeking behaviors; (4) preferences for tradit ional versus non-traditional approaches to health care, and (5) perceptions regarding the role of familie s in health care (Denboba et al., 1998). The Denboba et al. (1998) fi ndings are supported by a recent study of Hispanics and their access to and attitudes towa rds oral health care by Vazquez and Swan (2003) revealing that only 2% of the dentists located in Wichita, Kansas were of Hispanic origin. Moreover, none of them spoke Sp anish, although some dental offices provided Spanish/English translation. Several other aut hors have identified ba rriers and attitudes that affect access to health care within minority populations. The barriers and attitudes include low education level coupled with cult ural values and beliefs, language, lack of access to service, lack of dent al/health insurance, low income lack of recognition of oral health care, acculturation, and in accessibility to health provi ders of the same ethnicity (Aday & Forthofer, 1992; Manski & Magde r, 1998; Spector, 2000; Waldman, 1992). When examining the issue of racial disparity in HIV care and treatment, researchers found that some clinics and states have made progress in reducing disparity through a variety of programs (AIDS Alert, 11/01/02). One promising strategy was found to be contracting with minority co mmunity-based organizations to conduct treatment, education and outreach.

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34 Access to Oral Health Care The changing face of the HIV epidemic has increasingly affected poor people of color, populations that historically have experi enced lack of access to oral health care. Therefore, the New York State Department of Health AIDS Institute (2001) advised that health care providers ensure that every patie nt receiving treatment for HIV/AIDS have a culturally competent source of or al health care that is conveni ently located with variable office hours. To assist this effort, the New York State Department of Health AIDS Institute (2001) wrote an oral health clinical guide for primary care practitioners that included the following recommendations: Oral health care services should be fully integrated into other available primary care services for HIV-infected patients. Structural, financial, personal, and cultural barriers should be considered and addressed by the oral health care staff to ensure adequate access to oral health care services. Every patient should receive a comprehens ive initial examination that includes a medical and social history, and chief complaints. Extraoral head and neck examinations and oral soft tissue exams should be performed at each visit. A comprehensive dental treatment plan th at includes preventive and maintenance care should be developed and discus sed with the patient, and that any modifications to the treatment plan s hould be based on the patients general medical status rather than the patients HIV/AIDS status.

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35 The dental provider should immediately communicate to the patients medical provider any clinical findings that may indicate a change in the patients systemic health, or planned procedures that may impact their systemic health. Oral Health, At Risk Populations and Oral Health Disparities An editorial in the January 2002 issue of the American Journal of Public Health featuring an oral health theme, begins with the vital concern: The focus on oral health is critical (p.9), and documents the pressing oral health n eeds of underserved populations (Beetstra, Derksen, Ro, Powell, Fry, & Kauf man, 2002; Zabos, Northridge, Ro, Trinh, Vaughan, Howard, Lamster, Bassett, & C ohall, 2002). The most disadvantaged populations include people of color, the wo rking poor, and people with chronic illnesses and disabilities, populations that have previ ously been found to be underrepresented in household surveys (Zabos et al, 2002). Th e researchers sampled people who lived in dwellings and places that are often missed by conventional U.S. census listing protocols such as single-room occupancies, cars and cardboard boxes. Zabos et al. (2002) found that the most commonly self-re ported health complaint am ong adults in Harlem, New York was problems with their teeth and gums (30%). In May 2000, Oral Health in America: A Report of the Surgeon General was released (NIH, NICDR, 2000). In this report, the Surgeon General states, All Americans can benefit from the development of a Nationa l Oral Health Plan to improve quality of life and eliminate heal th disparities by facilitating collaboration among individuals, health care providers, communities and policymakers at all levels of society and by taking advantage of existing initiatives (p.2). This call for new efforts to eliminate

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36 disparities in oral health status and rates of oral disease particularly reveals the hidden epidemic of dental and oral diseases that largely affects poor people of color and those with chronic illnesses and disa bilities (NIH/NIDCR, 2000; Zabos et al, 2002). The report stresses the serious consequen ces that poor oral health has on a persons overall health and well-being. For example, adults in Ha rlem suffer from a high excess morbidity and mortality, yet little is known a bout the prevalence of oral dise ase in the population. It is no secret that New York has the highest number of reported cases of HIV and AIDS in the U.S. Building on the Oral Health in America report, the National Oral Health Call to Action is an important document that cr eates a broadly shared vision and fosters collaboration to promote oral health, and thereby general health and well-being. It promotes a focus on preventing oral disease, providing appropriate care and access to needed services. The two major goals of the National Oral Health Call to Action are consistent with those in th e Surgeons Generals report: To eliminate oral health disparities, and To improve quality of life. One of the guiding principles that pertains to providing oral health services and promoting health at the indivi dual and community level is to seek social equity. The key action element that upholds this principle and that relates to this study is to remove known barriers between people and oral hea lth services (NIH/NIDCR/U.S. Surgeon General David Satcher, May 25, 2000). Shiboski, Palacio, Neuhaus, and Greenbl att (1999) found that many HIV+ women have gone without dental care because of fear of dentists, lack of information regarding

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37 available dental care, unemployment, injec tion drug use and a perception of poor oral health. Among the 43% of these women who ha d not received dental care in the past year, the main reasons for not seeking care we re discomfort with or fear of dentists (27%), not making an appointment or not know ing which dentist to visit (21%), having financial issues or problems with insuran ce coverage (16%), and feeling discriminated against (9%). The perceived barriers faced by caregivers in obtaining dental care for their children on Medicaid included excessive waits, demeaning interactions with front office staff, negative interactions with and la ck of time with dentis ts, and discrimination because of being enrolled in Medicaid. In a ddition, other barriers that impeded access to dental care were difficulty in finding a practit ioner, difficulty in scheduling appointments, and inconvenient and unreliable transpor tation (Mofidi, Rosier, & King, 2002). The majority of persons with HIV/AIDS are minoriti es, and many of them receive their health care through Medicaid. When an HIV-infected individual is uninsured and is not covered under any other means, the Ryan White Care Ac t is the payor of last resort, and will pay for dental care when funding allows. As stat ed previously, few practitioners are willing to treat HIV+ patients unde r this payor source. Key findings from focus groups of women living with HIV/AIDS in Philadelphia, Los Angeles, Miami, and Savannah reveal that stigma and discrimination persist, especi ally with dental providers (Lake Snell Perry & Associates, Inc., 2003). What it Means to be HIV+ HIV/AIDS affects the lives of thousands in North America. In the U.S., HIV/AIDS has been associated with intravenous drug users, gay men, racial or ethnic

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38 minorities, and sex workers. Fear of HIV/ AIDS in American society suggests that HIV/AIDS is an illness with a triple stigma, that is, it is connected to stigmatized groups; it is sexually transmitted; and, it is a terminal and wasting disease. HIV/AIDS is a socially constructed dis ease. In the evolution of the social construction of HIV/AIDS, certain risk groups became associated with the disease. Because of their sexual orientation, drug use, race, or class, these groups are perceived to be at risk, whereas anyone who is not affiliated with these groups is largely excluded from the public dialogue surrounding HIV/AI DS. HIV/AIDS in women provides an example of how the social c onstruction of this illness ma y have serious social and medical implications for those who do not fit within the risk group categories. I am such the middle-American woman, I could be your daughter, I could be your Midwestern daughter who you have alwa ys felt so good about, who has always been upright and a good citizen and a ni ce girl and a mom and married, and all those things. If I told you Im HIV+, you would be shocked (Grove, Kelly & Liu, 1997). Persons living with HIV/AIDS experi ence hope, despair and hopelessness as distinguished by Kylma, Vehvilainen-Jul kunen, and Lahdevirta (2001). Hope is important in facing the prospect of living with a chronic disease such as HIV/AIDS (Katz, 1997) and helps in major stressful events and alleviat es emotional distress (van Servellen, Sarna, Padilla, & Brecht, 1996). On a general level, despair and hopelessness are connected to suffering, as is the concept of losing with this disease (Kylma, Vehvilainen-Julkunen & Lahdevirt a, 2001). Losing, or loss of joy, carefree time in life,

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39 safety, self respect and trust in oneself, othe r people, control over ones life, and systems are a few examples of what person s with HIV/AIDS have experienced. For years weve had the government telli ng us what to do. Weve had social workers and organizations telling us what to do, doctors[all] saying, This is in your best interest, and This is best fo r you, and We know exactly how you feel. And they havent got a bloody clue because theyre not living with it (Whittaker, 1992). Their experience is one of e normous upheaval due to the un certainty of a disease with vague symptoms, changing medical manageme nt, and social stigma (Katz, 1996). First and foremost are those living with HIV infection, but who have not been tested. Weitz (1989) looked at uncertainty in a c ohort of homosexual men and identified that many of them suspected they were HIV+ but had not been tested. The lack of confirmation of their serostatus was a significant source of their uncertainty, and that after their HIV infection was confirmed, they began to identify methods to cope with the uncertainty. Much of the uncertainty concer ned the unpredictable natu re of the disease, the long asymptomatic period following infection with the virus, and the often vague and confusing symptoms associated with opportuni stic infections. The potential impact of stigma on HIV+ individuals was docum ented by Laryea and Gien (1993) with respondents reporting that the uncertainty about their lives wa s coupled with intense fear of disclosure and rejection. Katz (1996) found that (1) all respondents described being diagnosed with HIV as a pivotal life event, and for some the diagnosis was a shock; (2) living with HIV was their impetus to begin l ooking at themselves with honesty and the world around them more clearly, and (3) pers ons living with HIV infection formed a new

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40 perspective on life, which is maintained through five core experiences. These experiences included surviving the HIV dia gnosis, taking care, livi ng in the present, seeking support, and apprecia ting the positive. Respondents indicated personal growth as a result of having this disease, and had a fi rm belief that this growth would not have happened without HIV as an impetus. Regardless of gender, ethnicity, class or sexual orientation, the prevailing stereotypes of AIDS stigmatize persons w ith HIV/AIDS as immoral (Stanley, 1999). Stigma damages or spoils identity by marki ng the person as having an essentially deviant disposition. A flawed identity interferes with or actually disqua lifies the stigmatized person from full participation in normative roles, statuses, and social relations. Therefore, many HIV+ persons fear the stigmatization and struggle with the discrediting implications of their serostatus. The following quotations are excerpted from vignettes in books that demonstrate some of what it means to be HIV+. The first person is a client of an HIV/AIDS comprehensive community-based service pr ogram in the Tampa Bay area who was infected through sex and who was di agnosed in 1993. She says: I dont blame anyone. It was my own responsibility. I should have used protection, even though at the time I was in fected there was no talk of women getting AIDS. We were the silent popul ation becoming infected. That makes me mad. All of the HIV-positive women I know have gynecological problems and none of the doctors really understand the connection to HIV. When I started to have problems I went to see a doctor. I told him I was positive and he put this big, red sticker on my chart saying I was positive. I was lying in the stirrups

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41 when he came in. He said, Remind us when you come in to tell us that youre positive so we can take extra precautions.s o that we can put hazardous material in a proper container. Afte r the exam he walks out. The nurse comes in and tells me I can get dressed. Then she told me to take the paper off the table and put my gown in a hazard bag. I dressed and left my gown and the table paper right where they were. Then I told the doctor I will never step foot in your door again, and I will make sure every HIV caseworker in Pinellas County knows how ignorant you are so no woman will ever have to be insulted by you. And that is what I did (Huston & Berridge, 1997, p.80). Another woman, infected through sex, and diagnosed in September 1994 says: Its almost like AIDS gives me some kind of freedom. Like it cant get any worse, so go for it. I have nothing to lose. Risks are not so risky, especially emotional risks. Before HIV, I wasnt ve ry assertive. I say what I feel now. AIDS has definitely made me a lo t stronger (Huston & Berridge, 1997, p.35). A 33-year-old advertis ing executive said: I think every HIV+ person goes through it and some dont get out of it; that this is the end. Why bother getting teeth fixed because youre going to be dead. Why bother doing this because youre going to be dead? Well, I got over that stage (Katz, 1996, p. 55). A father stated: My foster son, Michael, aged 8, was bor n HIV-positive and diagnosed with AIDS at the age of 8 months. I took him into our family home, in a small village in southwest England. At first relations with the local school were w onderful and Michael thrived

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42 there. Only the head teacher and Michaels personal class assistant knew of his illness. Then someone broke confidentiality and told a parent that Michael had AIDS. That parent, of course, told all th e others. This caused such pa nic and hostility that we were forced to move out of the area. The risk is to Michael and us, his family. Mob rule is dangerous. Ignorance about HIV means that people are fr ightened. And frightened people do not behave rationally. We could well be driven out of our home yet again (UNAIDS/WHO, 2003, p.31). Living in rural communities posed some mind-boggling circumstances for two women who were being diagnosed with HI V. A pregnant woman was asked quite forcefully by her doctor to have an a bortion, which she ultimately decided to do (Whetton-Goldstein, 2002, p.97). When anot her womans husband was tested for HIV after a car accident, the physicians encouraged her to be tested also, but she was too scared. She was tested two years later wh en a physician who was treating her, stuck himself with a needle that he had used on he r. After she left, the doctor began to worry about the possibility of contracting HIV. So then, after that, I had a whole lot of police cars co me to the house and that scared the life out of me because I didnt know what was going on. They told me that I needed to go to the hospital, and th ey escorted me to the hospital. I thought I had done some kind of crime or something (Whetton-Goldstein, 2002, p.98). The manner in which this last woman was taken to the hospital for HIV testing without giving her an explanation, and the manner in which the pregnant woman was forced into having an abortion indicates the extent of ignorance in rural communities, where people

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43 often react from fear, and w ithout understanding the issu es of confidentiality and patients rights. Ken worked as a marketing executive for a large health insurance company, and had not told any of his coworkers about havi ng the HIV infection. He believed that the virus did not affect his work performance, or pose any health risk to his coworkers, but he did worry that someone at work could access his health insurance records and discover his HIV status. Other personal friends knew of his diagnosis, but he waited more than one year after his partner died of AIDS, to attempt to begin another relationship. He now feels strongly that if he is going to have se x with someone, his partner will be told of Kens seropositivity and that they must use condoms (Derlega & Barbee, 1998, p.5). Lori told of her sexual pattern: If I have intercourse, I tell [the person] I am positive. Thats why I dont want to meet people or meet a new man. Because I go through a lot of wondering if I should tell em, or what should I do, how they going to react. I dont like meeting. But when I do, Ill be with them for awhile before I have sex with them. You know I tell them before that. You know if I feel like Im going to have sex, I tell them, You know its on you now, you do what you want to do, but Im HIVpositive. So whoever I been with knows (Whetten-Goldstein & Nguyen, 2002, p. 116). In an article Living with an HIV Diagnosis (AIDS Alliance For Children, Youth & Families, 2003, pp. 1,3), a 25-year-old woman wrote: I am HIV positive. The first time I said it out loud was an experience that compared with no other. Being HIV positive was a certainty, and my choices

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44 were either to be disillusioned or to a ccept it. Up until then, I had known exactly who I was and exactly what it meant to be me. Now I was somehow reinvented. But this reinvention was not part of my lifes plan. For weeks after my diagnosis, I was overwhelmed, under prepared and ga sping for air. Eventually my arms stopped flailing, my head stopped spinning, and I began to float. I decided that I wouldnt struggle against the labels, I would get past th e tides of stigma, and I would somehow grab a life jacket of accep tance and save my own life. From the time of my diagnosis until now, I have decide d to live life to its fullest. I reached out to my community to continue to heal. I reclaimed my value as a person and as a woman. I became driven with a cause. I was empowered to become a part of the healing process for others. I enc ourage and challenge anyone reading this whose mind may still be racing to let go. Allow you yourself the chance to live and taste life. A female friend of mine who is nearing age 50, gave me this perspective on being white and being HIV+: I think I contracted HIV when the condo m broke during intercourse when I was living in Africa. That was in the 1980s. For years, I avoided being tested for HIV because I was in denial of possibly being HIV-infected. When I finally did get tested, it was my decision. But I kne w that it put a veil of stigma and discrimination before me, when there had been none there before. I hardy told anyone about my diagnosis, because of fear, and the stigma and discrimination that it might bring into my life. Then I to ld my two coworkers. After that, I felt free, like a load had been lifted from me. I worked to regain the confidence that I

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45 had previously felt, and my life opened up. I am now an advocate for those with HIV/AIDS and feel like this has been give n to me as part of my mission in life (personal communication, September, 2001). Another friend of mine turned a difficult life situation into a career of teaching persons with HIV/AIDS how to live successfully with the disease. He is a long-term survivor of AIDS, has extensively researched his medical condition, and strictly adheres to his medication regimen. He contracted th e virus from his partner of 12 years who was a drug user; both of them were involved in hi gh-risk behaviors. He has been in his current relationship for ten years, and his partner remains HIV-negativ e. He credits his long-term survival to having access to the latest drug regimens from NIH, to his positive attitude and actions, and to keeping actively engaged in teaching a nd advocating for those with HIV/AIDS. I received an email from a local dental hygienist who wrote: Just thought I would share this tidbit with you. I w on't say which office this happened in, but the receptionist (office manager) came into my operatory with a patient's chart and pointed out that the pa tient indicated on his medical history that he was HIV+. This was my first time s eeing the patient, but he was a patient of record for many years and previously had his teeth cleaned by the other hygienist. She told me she was bringing th is to my attention in case I wanted to double glove or do anything else since th e other hygienist did. I told her I practiced using "universal precautions" and saw no need for her to "point" this out to me. She became slightly defensive implying I was being careless. We respect

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46 one another so it didn't create a disturban ce in the office, and I felt I might have educated her a little with my reply (personal communication, September 8, 2005). A recent study by researchers at the Univ ersity of California at Los Angeles on HIV stigma among health care workers toward their patients found that perceived stigma in clinical settings may have discouraged individuals from accessing needed health care services (Kinsler, Wong, Sayles, Davis, & Cunningham, 2007). Approximately onefourth of 233 low income, HIV+ persons in Los Angeles County reported perceived stigma from a health care provider. AIDSat home among us, a contorted all y, an alien who lands anywhere, with anyone, anytime. I ask you, would the Almi ghty feel as alone as I, as angry, afraid and abandoned as I who want to slay this monster named AIDS? What if a pair of wings sprouted through the cotton of your favorite t-shir t and flew you into the arms of a guardian angel. What if ...(Tartakoff, Lee, Blanton & Weiner, 1998). The Dental/Dental Hygiene Profession Approximately 168,000 dentists, 112,000 regi stered dental hygienists and 218,000 dental assistants work in the United St ates (CDC,2003). As re ported by the Florida Department of Health (2005), 6,537 dentists, and 7,458 dental hygienists were licensed in Florida as of June 30, 2004. Of these DHCPs, 6,488 dentists and 7,383 dental hygienists were actively practicing, and were bound to follow Florida Law as written in F.S. 466. Dental hygienists in Florida are required to work under the direct, indirect or general supervision of a dentist (F.S. 466.024). The only tasks or acti vities that dental hygienists may provide without supervision are educational programs, faculty or staff

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47 training programs, authorized fluoride rins e programs, and other services that do not involve diagnosis or treatment of dental cond itions, and are services approved by rule of the board (F.S. 466.023). This means that de ntal hygienists may not treat patients who are not first seen and examined by a licensed dentist; they are not legislated to be independent practitioners, nor are they in a position to refuse care. In the realm of this study, and bound by Florida Law, dentists are the ultimate decision-makers regarding the treatment of HIV/AIDS patients, and this is a study limitation. Three documents in the appendix discuss and compare the concepts of direct access, general supervision in the private office, and permitted functions and supervision by 51 states and the District of Columbia. As mentioned in the above paragraph, Florida has general supervision guidelines in the priv ate office, permitted functions that do/do not require the presence of a dentist, but is not a direct access state. Direct access means that a dental hygienist can initia te treatment based on their ow n evaluation of the patients needs and without the specific authorization of a dentist, treat the patient without the presence of a dentist, and can maintain a provider-patient relations hip (American Dental Hygienists Asso ciation, 2007). Ethical Practice in Dental Treatment The concept of human rights is at the fore front of the ethics literature, and is particularly so in textbook discussions about the duty of providing clinical care to patients with HIV/AIDS (Doyal, 1994b; Reamer, 1991). Ethical principles such as rights, duties and protecting others fr om harm should be followed in the clinical treatment of patients with HIV/AIDS. Rights are claims which it is socia lly accepted that persons are

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48 entitled to make in specific circumst ances (Doyal, 1997), and precede preferences (Dworkin, 1981). Rights provide moral structur e to social and professional life through specifying what people should do in particular situations even when they wish to do otherwise. In performing our duties, we are primarily obligated to take due care and caution about the health and safety of others. Patients also have rights. People who need dental care are entitled to expect that DHCPs will assume the duty to provide it to an acceptable professional standard. In a clinical sense, the patients right to autonomy translates in to the doctrine of informed consent (Doyal & Cannell, 1995). Besides info rmed consent, the moral duty to respect the autonomy of patients also necessitates prot ecting their confidentiality. If patients are unsure that their privacy will be respected, they will not cooperate in their treatment planning, and may not get dental ca re at all. In this way, th e principle of confidentiality becomes a public health issue. For example, it is in everyones interest that those with contagious diseases seek health care rather than avoiding it altoge ther because of their fear of unwanted public disclo sure. DHCPs would expect high standards of privacy for their own treatment. Patients have a right to expect the same. Patients should be treated fairly and w ithout discrimination. Discrimination based on the type of need with which patients pres ent is professionally unacceptable, as it is because of their race, creed or color (R ule & Veatch, 1993). Professional practice demands courage of its DHCPs, that is, thei r willingness to try to solve the patients problems in the face of personal risk. Dentists have the responsibility to treat HIV+ patients without bias or discrimination (Schulman, 1993). The law states that a workplace of public

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49 accommodation such as the dental office requires treating patients with disabilities (HIV infection is included in the lega l definition of disability). Therefore, HIV+ patients are protected by the ADA and other court decisions ( Shultz v. Hemet Youth Pony League,Inc., 943 F Supp. 1222 (C.D. Cal. 1966); Anderson v. Little League Baseball, Inc., 794 F Supp. 342 (D. Ariz. 1992); U.S. v. Morvant, 898 F. Supp. 1157 (E.D. La. 1995) which established that a de ntists referral of HIV+ pa tients to another provider who supposedly specialized in trea tment of such dental patients could be a pretext for unlawful discrimination if neither the dentis t nor his/her staff examined the patients mouths. Other court decisions did not support the findings of a dentists belief that an HIV+ patient posed a direct th reat to him and his staff, citing that available medical knowledge and implementation of universal pr ecautions significantly mitigated any risk posed by the patient ( Bragdon v. Abbott 118 S. Cr. 2196 (U.S. 1998); U.S. v. Morvant 898 F. Supp. 1157 (E.D. La. 1995). Every health care professional has the duty to assess the risk of infection based on objective and sc ientific information available to them in their respective professions. Th e dentists belief that a significant risk existed, even when maintained in good faith, did not relieve him from liability. A number of ethical dilemmas have evol ved around providing dental treatment to patients with or suspected of having HIV/AIDS. Researchers have found that up to 60% of patients with HIV/AIDS have oral manifestations of th e infection (Robinson, Sheiham & Zakrzewska, 1996). Therefore, DHCP are ofte n the first to discover the symptoms of HIV infection and to have to confront thei r findings with patients It is the DHCPs obligation to be truthful to patients to help them make choices about their future. In the case of HIV/AIDS, the health and safety of others is at stake. Many DHCPs are still

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50 concerned about the possible risks which they might incur in trea ting patients with HIV/AIDS, and they sometimes argue that th e moral balance has been shifted too much in the direction of patients rights. If a patient is HIV+ do DHCPs have the right to refuse treatment? According to Doyal (1997) this argument is unacceptable. DHCPs should be taught to show courage when facing minimal risk of infection when they are mandated by law to protect themselves with high levels of protection (Emanuel, 1988). There is no evidence that any DHCP has ever contract ed the infection from treating a seropositive patient. Transmissibility of HIV/AIDS History of Infection Contro l Related to HIV/AIDS During previous decades, most dentists practicing in North America were professionally prepared when it could be assu med that their concepts on infection control were based upon their undergraduate experience s. Only more recently as a consequence of AIDS, dentistry is being performed by masked, draped, and gloved DHCPs for whom direct patient contact is an anathema (Hardie, 1995). The November 15, 1985 Morbidity and Mortality Weekly Report (MMWR 34) announced that specific recommendations were being formulated for health-care workers (e.g., surgeons, dentists) who perform inva sive procedures and that separate recommendations were being developed to prevent HTLV-III/LAV (formerly used nomenclature for the HIV virus) transmission in prisons, other correct ional facilities, and institutions housing individuals who may e xhibit uncontrollable behavior (e.g., custodial

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51 institutions) and in the perinatal setting. It stated that separate recommendations had already been developed for children in schools and day-care centers. Six months later, in April 1986, MMWR (35) released the recommendations for health care workers that stated that dental personnel may be exposed to a wide variety of microorganisms in the blood and saliva of patie nts they treated. It also stated that infections could be transmitted in dental op eratories by blood or saliva through direct contact, droplets, or aerosols, and although not documented, indirect contact transmission of infection by contaminated instruments was possible. The re port also acknowledged that patients and DHCPs had the potential of transmitting infections to each other (CDC, 1986). Thus for the first time, the CDC outlined a set of infection-control strategies and recommendations for routine care of dental patients. A follow-up MMWR (1987, 2S) emphasized the need for health-care workers to consider patients as potentially infected w ith HIV or other bloodborne pathogens and to adhere rigorously to infection control proce dures for minimizing the risk of exposure to blood and body fluids of all patients. Thus recommendations for universal precautions were included in this August 1987 report. An update to the previous reports of 1986 and 1987 followed in 1988 ( MMWR 37), and stated that universal precautions we re intended to prevent parenteral, mucous membrane, and non-intact skin exposures of health care workers to bloodborne pathogens. In addition, immunization with hepatitis B vaccine (HBV) was recommended as an important adjunct to universal precau tions for health care workers who incurred exposures to blood.

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52 In 1989, the CDC provided an overview of the modes of transmission of HIV in the workplace, an assessment of the risk of transmission under various assumptions, principles underlying the control of risk, a nd specific risk control recommendations for employers and workers ( MMWR S6). This document also included information for the medical management of persons in the workplace exposed to these viruses. Purported or Actual Cases of HIV Transmission from DHCPs to Patients These infection control recommendations had been in place for four years when in 1990, health authorities released a study about an undisclose d dentist in Miami who was thought to have infected 28 of his patients. This dentist practiced for 30 years in Liberty City, an area with heavy drug use and one of the highest rates of AIDS cases in Miami. Ultimately, there was no conclusive tie f ound between the dentist and the 28 patients (No Tie Found, 1995; Jaffe, McCurdy, Kalish, Liberti, Me tellus, Bowman, Richards, Neasman & Witte, 1994). The report stated th at although infection control procedures were flawed, the dentist did not transmit HIV to the patients. Researchers said that the DNA in the dentists HIV was different from the DNA found in his patients, and no sign that the patients contracted the virus from one another through the de ntists tools existed. Another 1990 incident of HIV transmi ssion involved Dr. David Acer, a dentist with AIDS from West Palm Beach, Florida. According to the CD C and other health authorities, Dr. Acer had infected six of his patients. Based on DNA analysis, the CDC concluded that the strain of HIV that Acer carried was the same as the one found in his six patients (No Tie Found, 1995; Jaffe, et al, 1995; Neiburger, 1996). Therefore, the Florida Department of Health and Rehabilitative Services (HRS) and the CDC concluded that Dr. Acers practice was the only one of a health care worker with HIV infection in

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53 which HIV transmission to patients had occurr ed. The available evidence suggested that HIV was transmitted from dentist to patient rather than from patient to patient. Although the possibility of transmission of bloodborne infections from DHCPs to patients was considered to be small in 1993 (CDC, 1991 & 1992; Chamberland & Bell, 1992; Siew, Chang, Gruninger, Verrusio, & Ne idle, 1992), precise risks had not been quantified in the dental se tting through carefully desi gned epidemiologic studies. However, the Dr. David Acer incident pr ompted the CDC to publish new infection control guidelines for dental health care personnel (CDC, 1993; Ciesielski, Marianos, Ou, Dumbaugh, Witte, Berkel man, Gooch, Myers, Luo, & Schochetman, 1992). Whereas the precise event or events re sulting in transmission of HIV infection in Dr. Acers dental setting ha d not been determined, epidemiologic and laboratory data indicated that these infections probably were transmitted from the DHCP to patients, rather than from one patient to another (Cie sielski et al, 1992). Presumed modes of HIV transmission identified by the CDC incl uded sexual contact with Dr. Acer, from contaminated equipment, or from direct cont act with Dr. Acers blood either accidentally or intentionally (Hardie, 1995). Patient-to-p atient transmission of bloodborne pathogens to that point had only been reported in medical settings (Ciesi elski et al. 1992). Following release of the CDC report of the Dr. David Acer incident ( MMWR, 1991:40), public concern about the transmission of HIV in the dental office increased. The case created media buzz and a public fear of dentistry (Neibur ger, 1996). People surveyed expressed a decreased willingness to re main in the practice of dentists infected with AIDS, or those who treated infected patients (Cohen, Grace & Ward, 1992). The alarmist climate resulted in heavy pressure on the dental profession to show that dental

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54 offices were safe places, and numerous laws, re gulations and procedures were enacted to support this premise (Neiburger, 2004). In th e midst of the alarm, Congress requested the General Accounting Office (GAO) to assess the methods and evidence used by the CDC in arriving at the above conclusion. Ultimat ely, the GAO found the CDC investigation to be thorough and competent (GAO, 1992). Controversy and speculation was fueled by the inability to determine exactly how the transmission from Dr. Acer to hi s patients occurred. Articles in Lears Magazine and The New York Times plus a segment on the televisi on news magazine Minutes presented findings of independe nt investigators (Barr, 1994; Barr, April 16, 1994) casting doubt on the conclusion that Dr. Acer had infect ed the six patients with the HIV virus. Barr (1996) responded in the Annals of Internal Medicine that as an investigative reporter, he had access to thousands of page s of documents related to the lawsuits brought by the patients against the dentis ts insurance company. These documents included medical records, legal depositions, scientific analyses, and the CDCs epidemiologic field work and molecular anal yses -information not previously made public. Smith (1996) confirmed this info rmation and concurred that the patients supposedly infected by Acer also reportedly enga ged in behavior that put them at risk for HIV. Neiburger (1996) said of the CDC inve stigation: In essence, the CDC compared apples with oranges using a warped ruler a nd a peach while flippi ng a bent coinfuzzy science (p. 26). The following information explores the si x patients supposedly infected by Dr. Acer. Although Patient A (Kimberly Bergalis) told federal and state investigators that she was a virgin, her vagina and anus test ed positive for human papillomavirus (HPV)

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55 type 18, a sexually transmitted infection; a nd a court ordered gyneco logical examination found the condition of the hymen to be consistent with having engaged in sexual intercourse. Harold Jaffe of the CDC confir med that he had been given a copy of the gynecological report in 1990, months afte r the news about Patient A had broken worldwide. Jaffe gave the report to the CD Cs general counsel office which shielded it from access through a Freedom of Informati on Act. Shortly after the gynecological examination, Bergalis attorney met with he r to make sure she was telling the truth (Smith, 1996). She left the office with a gift of $5,000 from her attorney, a blatant violation of Florida bar guideline s. He also gave Bergalis a car as a gift. The question remains as to whether the presents were given to make sure that she st uck to the story that she was a virgin, thus en suring a large payout to he r parents after her death. The remaining five patients were already aware of the legal case by Patient A, and the CDCs dentist transmission theory about their risk factors and sexual partners. Therefore, they had a monetary stake in re maining consistent with the CDCs findings. Patient I was the last patient to accuse the dentist. Barr (1996) stated that whereas the CDCs investigators had access to insurance billing records of the family, they did not intensely scrutinize them. The patients record s directly contradict her claims about the number of dental visits she made, and the kinds of dental treatment that she received. In fact, the records suggest that Patient I may never had been treated by Dr. Acer, meaning that she had no risk of exposure. Patient G said that he had used intrav enous drugs once in 1973, and had only two female sexual partners since 1986. In a sw orn deposition, an acquaintance of Patient G stated that the patient had frequented a crack house three to four times a week in the mid-

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56 1980s, that he traded crack for sex, and that he had unprotected intercourse as many as 50 times with a prostitute who later died of AIDS. Whereas Patient C claimed that he had ne ver had homosexual contact, in reality he had had anal intercourse at least six times with another ma n. In this instance, the CDC investigators reported for the first time that they had identified one male sexual partner who had tested negative for HIV, but overlooked this inconsistency in their epidemiologic analysis (Ciesielski et al. 1994). When Patient B was first tested for HI V in 1990, she said that she had received blood during surgery between 1975 and 1985. Although she had several major surgeries during that time, her hospital ch arts show no record of any transfusion. In a deposition given in May, 1991, the patient disclosed an extramarital affair in the late 1970s, but failed to report this information to CDC i nvestigators. When Barr (1996) contacted the sexual partner of Patient B in 1993, the partner said that he had never been tested for HIV, had not been contacted by the CDC, and had not had sexual relations with the patient. These issues indicate that the patie nt was not truthful a bout her sexual history when she was first asked by investigators. Finally, evidence surrounding Patient E was the most puzzling. This patient was first diagnosed with HIV in 1988, and at that time, she believed that her boyfriend had infected her because he had known risk factors. Later, Patie nt E told investigators that her boyfriend had tested negative for HIV when she discovered her HIV+ status, and that he tested positive later. Barr (1996) f ound that her 1992 deposition testimony did not concur with the information presented by the CDC as to when she and her boyfriend learned of their infections.

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57 Barr (1996) advanced many arguments that refuted CDCs evidence and stance. One of these seemed especially important. In an unpublished letter to the CDC in 1990 before any information about the case becam e public, one of Ciesielskis co-authors (Witte, Unpublished communication) called the analysis linking the dentists and the patients viral strains scientifically inconclusive. And although numerous calls to Wittes office were made, none were returned. Again, Barr (1996) told of Ciesielski a nd colleagues who sought to dismiss the epidemiologic and molecular questions that he raised by arguing that he presented evidence related to private litigation generate d by the case. Barr stated that six of the eight scientists who participated in research critical of the CDCs conclusions received no money from the insurance companies and had no financial stake in the outcome of their research. Several of the researchers claimed that their affiliation with the research had affected their chances of getting grants. A Washington Post reporter presented a commenta ry on both viewpoints (Brown, 1996). Brown stated that in Barrs and the sc ientists criticism of the CDC investigation, the argument was built that the investigation was fatally flawed and that the conclusions of the investigation were probably wrong. He sa id that they failed to present information that supported an alternative explanation. Related to the viral stra ins of the dentist and the patients, Brown (1996) wrote that it was unfortunate that neither the CDC investigators nor Barr had offered a chart quan tifying the degree of similarity between the virus samples. It is a case that still mystifies most everyone in the dental community. The strange case features disp utable DNA sequencing tests, dubious legal strategies,

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58 overwhelming media attention, and grieving families. Despite the mountains of documentation, there is still no known mode of transmission. Despite numerous theories, the origins of this series of cases remain unsol ved. Until it is resolved, it may continue to spawn more questions than answers. Did A cer infect his patients through a contaminated handpiece? Did he intentionally commit cold-blooded murder? Did he infect them at all? We may never know the answers to these questions. Preventing Transmission of Bloodborne Pathogens: 2003 These questions propelled the CDC to c ontinue reviewing its infection control recommendations. According to the latest CDC report on infection control procedures ( MMWR 2003; p.37), the goal of a dental infection control program is to provide a safe working environment that will reduce the risk of health care-associated infections among patients and occupational exposures among DH CPs. A successful infection control program prevents or reduces the potential fo r disease transmission from patient to DHCP, from DHCP to patient, and from patient to patient. Components of infection control include a written exposure control pla n, annual employee training, hepatitis B vaccinations and post-exposure follow-up. As of December 2001, occupational exposure to HIV has resulted in 57 documented cases of HIV seroconversion among healthcare personnel (HCP) in the United States ( MMWR report (52, RR-17; CDC, 2003). Personnel subject to occupational exposure should receive infection control trai ning when they begin their job, when new tasks or procedures affect their occupationa l exposure, and at the least, on an annual basis. Training for DHCPs who may be expos ed to infectious ag ents in the workplace

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59 should include: (1) a description of their exposure risks; (2) a review of prevention strategies and infecti on control policies and procedures; (3) a discussion regarding how to manage work related illness and injuries, and (4) a review of work restrictions for an exposure or infection. Including DHCPs w ith minimal exposure risks (for example, administrative employees) in education and tr aining programs may enhance facility wide understanding and importance of infection-control principles. Previous CDC recommendations regarding in fection control for dentistry focused primarily on the risk of transmitting bloodborne pathogens among DHCPs and patients and use of universal precautions to reduce risk. Universal precautions treated all blood and body fluids as potentially infectious agents and involved preventive practices such as careful handling of sharp instruments, usi ng rubber dams to minimize blood spattering, handwashing, and wearing prot ective barriers (g owns, masks, gloves and protective eyewear). In 1996, the term standard precautions was adopted and replaced universal precautions. Standard precautions integrated and expanded the concept of universal precautions into a standard of care designed to protect health care personnel and patients from infectious pathogens that can be spread by blood, other body fluid, excretion, or secretion. Because saliva always has been considered a potentially infectious substance, no operational difference exists in clinical dental practice be tween universal and standard precautions. For DHCPs who are infected with or exposed to HIV, the MMWR report (52, RR-17; CDC, 2003) suggests the following work restrictions: Do not perform exposure-prone invasive procedures until counsel from an expert review panel has been sought; the panel should review and recommend procedures that personnel can perform, taking into account specific procedures as well as skill and technique. Standard

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60 precautions should always be observed. Re fer to state and local regulations or recommendations (p.8). Risk Websters Ninth New Collegiate Dictionary (1988) defines risk as (1) the possibility of loss or injury; a dangerous element or factor, an d (2) to expose to a hazard or danger (p. 1,018). The definition of ris ky means accompanied by or involving risk or danger. In this study, the term risk is a ssociated with the risk of becoming infected with HIV/AIDS in a clinical dental setting. From an epidemiological viewpoint, risk factors are those factors whose presence is associated with an increased probability that disease will develop later (Mausner & Kramer, 1985). Risk factors may be unchangeab le, or susceptible to change. Even when there is a strong statistical association be tween a risk factor and a disease, not all persons with the risk factor will deve lop the disease. Moreover, the absence of the risk factor does ensure absence of the disease. Munjal (1994) states that ri sk factors for exposure exist within the patient, for transfer from pa tient to health care worker, and for transfer from health care worker to patient. In each of these pathways, the risk of transmission depends on the following conditions: (1) the number of HIV-infected individuals in the population; (2) the frequency of exposure to contaminated medical instruments; (3) the relative infectivity of the viral strain, and (4) the concentration of virus in the blood. The two most important risk factors fo r contracting HIV for women living in Florida are using drugs and having sex with a partner who uses drugs (Knox & Sparks, 1998). Thus, the two major exposure routes for HIV for women living in Florida with

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61 HIV/AIDS are injection drug us e (9%, 13%); and heterosexual contact with an injection drug user (54%, 55%; Florida Department of Health, 2003). The two major exposure routes for men living in Florida with HIV/ AIDS include men having sex with men (48%, 46%), and heterosexual contact (15%, 16%; Florida Department of Health, 2003). DHCPs Perceptions of Risk Dentists think of themselves as more c ontinually at risk for AIDS than do other types of health care workers (Verrusio, Ne idle, Nash, Silverman, Horowitz, & Wagner, 1989). Dentists perceptions of their occupational risk of HIV infection are important, because concerns about risk assessment of HIV infection may jeopardize the amount and quality of care provided to HIV+ patients (Kunzel & Sadowsky, 1993). Perceived professional and moral obligations to treat HIV+ patients were high in a study of dentists in Mexico City with 35% of dentists percei ved the risk of contracting HIV infection as considerable to very strong (Maupome Acosta-Gio, Borges-Yanez, & Diez-deBonilla, 2000). Additionally, only 54% of the respondents agreed that clinical precautions reduced occupational risks. Wh ereas this study was recent, it revealed contradictory attitudes toward HIV+ individuals and limite d understanding of infection control recommendations. The same research ers (Maupome, Acosta-Gio, Borges-Yanez, & Diez-de-Bonilla, 2002) interviewed 180 dentists in 1999 using the same methods as in a 1992 survey. Overall, 79% of study participan ts still perceived the risk of contracting HIV infection as considerab le to very strong. A recent study by King & Muzzin (2005) of dental hygienists in thirteen states found that 54% of respondents felt that treat ing patients with HIV/ AIDS increased their personal risk for contracting HIV. Sixt y-four percent of respondents reported always

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62 using extra precautions with HIV/AIDS, and hepati tis patients (60%). In addition to using extra precautions, 66% said they would not use an ultrasonic scaler when treating HIV/AIDS patients, or hepatitis patients (59%), which indica ted an alteration in clinical practice. Again in this study, other findings were more surprising: 45% of dental hygienists reported that HIV was able to be transmitted via saliva, 41% of dental hygienists reported that HIV was able to be transmitted through splash/splatter, and 30% believed that HIV was able to be transmitted through dental aerosols. To date, there has been no evidence of HIV or hepatitis C having been transmitted through aerosols or saliva in the dental setting ( MMWR 2003). This type of data is important, because the epidemic is 26 years old, and a high number of respondents still reported feeling a risk of occupa tional transmission of HIV. Other Health Care Provid ers Perception of Risk The literature on AIDS has asserted that fear and risk of contracting HIV is a significant concern among health care work ers (Jemmott, Freleicher, & Jemmott, 1992; Jemmott, Jemmott & Cruz-Collins, 1992; Maupom e, Acosta-Gio, Borges-Yanez, & Diezde-Bonilla, 2000; Kunzel & Sadowsky, 1993). Jemmott, Freleicher, and Jemmott (1992) found that nurses who were increasingly exposed to high-risk groups for HIV/AIDS perceived that caring for them amplified their risk of HIV infection, even when universal precautions were used. Similarly, Jemmott, Jemmott and Cruz-Collins (1992) found that nursing students who had less AIDS knowledge and who perceived themselves to be at greater occupational risk of b ecoming infected with HIV expre ssed stronger intentions to

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63 avoid caring for AIDS patients. Scherer, Haughey, and You-Wu (1989) revealed that half of the nurses surveyed were fearful of contracting HIV/AIDS, and another 20% were unsure of their risk. Half of respondents agr eed that they would worry about putting their families, friends and colleagues at risk if they cared for individuals with AIDS, whereas 35% felt that caring for a patient with AIDS could affect their relationships with significant others. The CDC estimates that the potential risk of transmitting HIV in the workplace is between 12 to 60 times less than the risk of transmitting hepatitis B (Hardie, 1995). The fact that dentists feel a greater level of comf ort with patients with Hepatitis B than with HIV+ patients defies the scie nce that has been validated (Neidle, 1994). Whereas there are limits to how accurately epidemiologist s can calculate minimal risk, the research demonstrates that the risk of contracting HIV from a patient during a dental procedure is close to zero (Henderson & Beekman, 1994). Court decisions also have shown that the risk of transmission in the dental clinic or office is too low to justify discrimination against HIV+ patients (Burris, 1994). Furthermore, there was no evidence of HIV transmission in the occupational setting of 245 health care workers in Italy who participated in a 5-year su rveillance program (Baldo, Florea ni, Dal Vecchio, Cristofoletti, Carletti, Majori, Di Tommaso, & Trivello, 2002). After exposure of the healthcare workers and during the follow-up period, there were no seroconversions to any of the viral markers. Therefore, it was concluded that the accurate post-exposure follow-up revealed a lack of transmission of HBV, HCV, and HIV.

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64 Public Perceptions of Risk Although the risk of transmission in the dent al clinic or office may be virtually non-existent, a study of almost 500 patients in Me xico City revealed that more than three fourths of the patients were concerned about the risk of contracti ng infections at the dental office and did not intend to conti nue treatment where pa tients with HIV/AIDS were receiving treatment, or where th e dentist had HIV/AIDS (Irigoyen-Camacho, Zepeda-Zepeda, Maupome, & Lopez-Camara, 2003). Early in the HIV epidemic, a cultura l comparison of attitudes among hospital dental practitioners and dent al students in their final ye ar of study was conducted in Glasgow, Scotland, and Los Angeles, Califor nia (Samaranayake, Figueriredo, Rowland, & Aitchison, 1990). A significant proportion of respondents in both counties said that they would not visit thei r dentist if their provider treate d AIDS patients, and significantly more Americans thought that AIDS could likely be transmitted in a dental clinic. A survey of public attitudes towards dentis ts who were HIV+ or who had AIDS was conducted on two occasions, three months apar t in Dartford and Tunbridge Wells, Kent, England (Harwood, Newton, & Gibbons, 1995). During the three months, a TV show about this issue was shown. The results indica ted that the public pe rception of risk of acquiring HIV infection through de ntal treatment was low. Transmissibility of HIV/AIDS to Patients and to Dental Health Care Professionals The Dr. Acer incident prompting adoption of stricter infection control procedures to prevent the spread of HIV via dental pr actice may have pacified a concerned public and the conscience of dental a ssociations and licensing bodies (Hardie, 1995). However,

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65 with all of the panic, fear and publicity surr ounding the AIDS epidemic, one critical fact is often missed -there never have been any documented cases of DHCPs getting occupational HIV (Neiburger, 2004). Because HIV is spread primarily by bl oodborne pathogens, it is essential to eliminate or isolate hazards to patients a nd DHCPs by using things like needle-retraction devices and puncture-resistant sharps containers. An MMWR report (CDC, 2003) states Although transmission of bloodborne pathogens in dental health-care settings can have serious consequences, such transmission is rare Exposure to infected blood can result in transmission from patient to DHCP, from DHCP to patient, and from one patient to another. The opportunity for transmission is greatest from patient to DHCP who frequently encounter patient blood and blood-contaminated saliva during dental procedures (p.10). Since 1992, there have been no reports of HIV transmission from DHCP to patients. The majority of DHCPs who are infected with a bloodborne virus (for example, hepatitis B, hepatitis C and HIV) do not pos e a risk to patients because they do not perform activities that meet the necessary conditions for transmission. In fact, for DHCPs infected with a bloodborne virus such as HIV to pose a risk to patients, they must: (1) have the HIV virus circulating in the bloodstream; (2) be injured or have a condition such as weeping dermatitis that allo ws direct exposure to their blood or other infectious body fluids, and (3) allow their bl ood or infectious body fluid to gain direct access to a patients wound, traumatized tissue, mucous membranes, or similar port of entry. Therefore, transmission cannot occur unless all three conditions exist.

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66 The risk of occupational exposure to bl oodborne viruses is mainly determined by their prevalence in the patient population and the nature and frequency of contact with blood and body fluids through percutaneous or permucosal routes of exposure (breaks in the skin or mucosa). The actual risk of b ecoming infected after an occupational exposure to a bloodborne pathogen is influenced by three factors: (1) the size of the inoculum; (2) the route of exposure, and (3) the susceptibil ity of the person exposed. Bloodborne pathogens present different levels of risk to DHCPs. Nationally, the risk of HIV transmission in dental settings is extremely low. In fact, just 57 cases of HIV have been documented among health-care personnel since 1981, but none have been documented among DHCPs Prospective studies worldwide have s hown that the average risk of HIV infection after a single percutaneous expos ure to HIV-infected blood is 0.3% (range 0.2%-0.5%), and a mucous membrane exposure is approximately 0.1% ( MMWR 2003). After an occupational exposure to blood has occurred, post-exposure management is an integral component of preventing infection, and first aid should be administered as necessary. Therefore, puncture wounds and other injuries to the skin should be washed with soap and water, and mucous membranes should be flushed with water. DHCPs who have been exposed should report the exposur e to the infection c ontrol coordinator or other designated person at the worksite, who should then refer the exposed staff member to a qualified health care professional who w ill complete the necessary reports. The 2001 guidelines ( MMWR, 2001) provide guidance to clinic ians and exposed DHCPs regarding when to consider HIV post-exposure prophylaxis and that enhance the dental hygienists ability to practice. Hygienists are not required to complete continuing education requirements during the biennium in which they receive initial licensure.

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67 HIV/AIDS Continuing Educa tion for Dental Personnel Effective May 11, 2005, dentists and dental hygienists are no longer required to complete instruction in laws, rules and et hics governing the practice of dentistry and dental hygiene to renew thei r license (Florida Department of Health, 2004). The 2006 legislation amended the requirements for HIV/ AIDS where a dentist or dental hygienist must complete a course in HIV/AIDS prior to their first license renewal, and a Domestic Violence course is now require d every third renewal period. Dentist 30 hours that must include: 2 hours in the prevention of medical errors 2 hours in domestic violence (every third biennium) In addition to the 30 hours, each dentist must complete a CPR course at the basic life support level, which include s training in cardiopulmonary resuscitation (CPR) at the basic support level, including one-rescuer and two-rescuer CPR for adults, children, and infants; the relief of foreign body airway obstruc tions for adults, childre n, and infants; the use of an automatic external defibrillator (A ED); and the use of ambu-bags resulting in certification or recertifica tion by the American Heart A ssociation, the American Red Cross or an entity with equivalent requirements. Dental Hygienist 24 hours that must include: 2 hours in the prevention of medical errors 2 hours in domestic violence (every third biennium) In addition to the 24 hours, each dental hygienist must complete a CPR course at the basic life support level, which includes training in cardiopulmonary resuscitation (CPR) at the basic suppor t level, including one-rescuer and two-

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68 rescuer CPR for adults, children, and infa nts; the relief of foreign body airway obstructions for adults, children, and infant s; the use of an automatic external defibrillator (AED); and the use of ambu-bags resu lting in certification or recertification by the Americ an Heart Association, the American Red Cross or an entity with equivalent requirements. All credit hours must be earned within th e biennium for which they are claimed. International Picture: Treatment of HIV/AIDS Patients The literature is rich with articles about medical and dental providers who are wrestling with the issue of treating versus not treating HI V/AIDS patients. Looking at the international picture of dentistry a nd HIV/AIDS is important, as the pandemic continues to spread worldwide. Fears rega rding the occupational transmission of HIV infection have prompted changes in dentistry s approach to infection control. However, fear, ignorance and uncertainty have produced irrational behavi or of HIV-negative dental staffs toward patients with HIV infection (Fukuda, H., 1993). The willingness of dentists to treat HIV+ persons is the issue. A study of doctors and dentists in Singapore disc overed that 74% expressed fear of contracting AIDS from patients, and 85% agreed that their staff members would be very ups et at treating them (Lee, Yong, & Tan, 1989). A later study conducted on medical and dental practitioners in Singapore demonstrated that although a la rge majority felt th ey had the ethical obligation to treat HIV+ patients, only half of them said they would be willing to do so if they were given the choice (Chan, Khoo, G oh, & Lam, 1997). These more recent data were an improvement over 1989 findings. A study of Italian dentists (Angelillo, Villari,

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69 DErrico, Grasso, Ricciardi, & Pavia, 1994) revealed that 72% of dentists would treat HIV+ patients, and 67% would treat patients wi th AIDS. Dentists were more willing to care for an HIV+ patient if they were involve d in specialties with high blood contact, if they had previous contact with HIV+ patients, and if they did not consider saliva a possible route of transmission of HIV. Alte rnately, 12% of dentists refused to treat patients at risk for AIDS, or those who were HIV+ (9.4%). In this study, willingness to treat was the most significant predictor of treating an HIV-infected patient. A study of Dutch dental hygienists showed th at fear of infection appeared to be negatively correlated to experience in treati ng HIV-infected patient s (ter Horst, 1993). An earlier study of Amsterdam dentists by te r Horst, et al, (1989) found that 30% of respondents were definitely fearful of AI DS and wanted additional information or training on this topic. A study of the willingness of general practice dentists in Brazil indicated that only 44% were willing to provide treatment to HI V+ patients (Sposto, Goncalves, Ferracioli, Porter, Afonso, el-Maaytah, Di Alberti, & Sc ully, 1994). Other Brazilian researchers reported that there was still prejudice and i gnorance about the risk of HIV/AIDS among both dental surgeons and patients (Discaccia ti & Vilaca, 2001). Fifty-two percent of dentists surveyed in England and Wales said they treated patients at high-risk for AIDS and hepatitis B (Wilson, Burke, & Cheung, 1995). Associations were found between willingness to treat high-risk category patie nts and number of years since graduation, gender, number of postgraduate courses attende d, and practice type. In the Republic of Ireland, a study of dentists demonstrated a fear of HIV to themselves, other patients, and their practice which indicated that attitudes related to dangerousness remained a

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70 significant obstacle in the treatment of patients with HIV infection (Gibson, Freeman, & McCartan, 1997). Seventy-four percent of den tists surveyed in Mexi co City reported that they would be willing to tr eat HIV/AIDS patients, whereas the remaining 26% were not willing to treat them (Irigoyen, Zepeda, & Lopez-Camara, 1998). The opposite findings among dental health care workers in Japan revealed that the majority of respondents were hesitant to treat HIV+ patients, and only 22.4% had the same attitude towards treating HIV+ and HIV-negative patie nts (Kitaura, Adahi, Kobayashi, & Yamada, 1997). The incongruence between perceived know ledge, reported practice and attitudes of dentists in Nairobi, Kenya, suggested a need for continuing education courses to enable them to practice with due care in treating HIV/AI DS patients (Gachigo, & Naidoo, 2001). The results of this study also indicate d that a greater compliance with universally accepted guidelines for infection control is n eeded. The same results were found in a South African study (Darling, Arendorf, & Samaranayake, 1992). Only 45% of dentists were prepared to provide continuing care to HIV+ patients, and therefore, further educational efforts on HIV infection and its im plications in dentistry were suggested for these providers. A study of infection cont rol among dental hygien ists in Italy also supported these findings (Angelillo, Nardi, Rizzo, & Viggiani, 2001) as only 37% of respondents knew all five oral manifestati ons of AIDS. This study suggested that educational programs are needed to improve knowledge about the oral manifestations of AIDS to support dentists in providing early diagnosis, and about the correct use of universal precautions for preventing infections in the dental setting. Finally, a study in Southeast China of 454 physicians and physician assistants revealed that only 40% of

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71 respondents were willing to provide care for HIV-infected individuals (Cai, Moji, Honda, Wu, & Zhang, 2007). What justifies me doing this now? DHCPs in other states have contributed to the literature by conducting studies of dental hygienists and dental hygiene students and their attitudes, intentions and behavior towards treating HIV/AIDS patients. The most recent study surveyed dental hygienists in thirteen states (Florida was not included) to investigate the infection control practices of practicing dental hygienists, and to docume nt the attitudes and practices of dental hygienists toward patients w ith infectious diseases (King & Muzzin, 2005). This study found that 54% of respondents felt that treat ing patients with HIV/ AIDS increased their personal risk for contracting the disease, and almost 64% reported th at they always used extra precautions with HIV/AIDS patients. An alteration in clinical practice habits was reported by 66% of respondents who said that they would not use an ultrasonic scaler when treating HIV/AIDS patients. Another recent study was c onducted in Maryland and found that dental hygiene students displaye d no bias toward homosexuals, and showed minimal bias toward individuals with AIDS (Cohen, Romberg, Dixon, & Grace, 2005). A previous study of Pennsylvania dental hyg ienists indicated that 85% of respondents possessed a moderate or high level of worry concerning their treatm ent of AIDS patients (Snyder, 1993). An Illinois study revealed that 45% of dent al hygienists believed that healthcare workers should not refuse care to people with AIDS. However, more than 50% said that they would qu it their jobs before working with someone who had AIDS (McCormack-Brown, 1991). Dental hygienists in Mississippi were asked about treating

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72 patients with infectious diseases (Dan iel, Silberman, Bryant, & Meydrech, 1996). Whereas most hygienists (98%) believed that barrier techniques were effective in stopping disease transmission, some believed th at patients infected with HIV/AIDS (43%), hepatitis B (31%), or tuberculosis ( 40%) posed a threat to DHCPs, and were best treated in public clinics rath er than private practice setti ngs. The results of a study by Haring and Lind (1992) indicated that the dental hygiene students in Ohio demonstrated a significant negative bias toward persons with AIDS. Literature searches have not provided the same type of studies of Florida dental hygienists. Attitudes Gerbert, Badner and Maguire (1988) assessed DHCPs attitudes toward people at risk for HIV, and those with AIDS in terms of willingness to treat them. Dentists who were over 43 years of age held attitudes that represented greater barr iers to providing care for persons at risk for, and those with AIDS Data also showed that DHCPs attitudes were more favorable if they perceived a greate r percent of patients in their practice to be at risk of getting AIDS. Whereas some stigmatizing attitudes and discriminatory practices are obvious, others remain hidden, and there is no clear relationship betw een attitudes and behavior in this circumstance (UNAIDS, 2004). Some st udies have found that people who express negative attitudes toward HIV-infected indivi duals, may provide supportive care for an HIV+ member of their own family. Alte rnately, some people who deny any negative attitudes towards people who are HIV+ may activ ely discriminate against them in certain settings, such as providing health care. Some interventions that are designed to reduce

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73 discriminatory attitudes may have a more ra pid and profound effect on reported attitudes than on embedded attitudes that influence a persons behavior. Researchers have found it difficult to collect information about behavi or towards those who are HIV+ (Sadowsky & Kunzel, 1994). However, for lack of better m easures, questions about peoples attitudes are likely to remain vital in attempting to track changes in negative attitudes towards people with HIV. People who have been diagnosed with HIV/ AIDS feel the stigma associated with it (Green, 1995). The high level of stigma associated with HIV is a feature of the disease, and agencies that support people with the vi rus are concerned about the severe social consequences that accompany this particular diagnosis. This stigmatization extends to HIV+ persons who wish to access dental care Green (1995) found that people with HIV clearly felt marked out and professed to hold more liberal attitudes about people with HIV than the general populati on. Therefore, it is possibl e that while claiming to hold non-stigmatizing attitudes, many people in the general public may act in stigmatizing ways. Some health care workers attribute negativ e characteristics to people with AIDS (Katz, Hass, Parisi, Astone McEvaddy, & Lucido, 1987). Many health care workers have an undue fear of AIDS patients (Blumenfield, Smith, Melazzo, Seropaian & Wormser, 1987). These studies also revealed that more social rejection was expressed toward AIDS patients. Katz, et al. (1987) concluded that the extr eme negative attitude toward AIDS patients resulted from their per ception that these patients were responsible for their own illness. Regardless of why some health professionals feel discomfort when caring for HIV+ patients, it is important to r ealize that their ethica l attitudes are at the

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74 core of being able to treat them succe ssfully. Whereas continuing education in HIV/AIDS is now mandatory for health care professionals and technicians, many still appear to express unreasonable be liefs and attitudes about AIDS that are not apparent for other contagious diseases. Whereas DHCPs are considered to be at low risk of contracting HIV/AIDS, they have ten times greater ri sk of contracting hepatitis B and becoming chronic carriers (Seacat & Inglehart, 2003). Grace and Cohen (1993) surveyed Maryland dentists about their attitudes toward treating AIDS and hepat itis patients. Based on self reports, oral surgeons (58.3%) were the most willing to treat AIDS patients than were general dentists (43.1%) or periodontists (31.1%). Oral surgeons also were more like ly to have treated AIDS patients than were general dentists or periodontists. These findings suggest that direct contact with AIDS patients may promote willingness to treat them. Respondents were asked whether they agreed with the American Dental Association (ADA) position that all dentists had a professional responsibil ity to treat AIDS patients. Findings showed that only 23.9% of periodontis ts, 33.3% of general dentists and 42.9% of oral surgeons agreed with the ADA position. Despite their training and e ducation, many health profe ssionals share many of the same attitudes toward AIDS and HIV+ patients as the lay community. Some health care professionals experience anxiety and uncertainty when treating those with HIV/AIDS, due to stigmatizing beliefs and prejudices. Some studies have demonstrated bias by health care professionals agai nst AIDS patients (Sears, & H o, 2006; Kinsler, et al, 2007), whereas other studies have identified the lack of basic knowledge about AIDS (Cai, et al, 2007). The University of California at Lo s Angeles (UCLA) study (2006) found that 56

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75 percent of skilled nursing fac ilities, 47 percent of obstetricia ns, and 26 percent of plastic and cosmetic surgeons would not accept HIV+ patients for services that were commonly provided to HIV-negative patients. The la rge number of health care providers who admitted that they would not treat HIV+ pa tients indicates a broad lack of knowledge about the laws prohibiting such discrimination. This report is consistent with studies from the mid-1990s showing high levels of HIV-discrimination by dentists and other health care providers. Since then, very fe w studies had been c onducted to measure HIVdiscrimination in health care. For exampl e, one study found that both medical students and practicing physicians held harsh and judgm ental attitudes toward persons with AIDS as compared to persons with leukemia (Kelly, St. Lawrence, Smith, Hood & Cook, 1987a, 1987b). Another article published by Kelly, et al, 1988) reported that many nurses had negative attitudes toward patient s with HIV/AIDS that resulted in an unwillingness to interact with them, even casually. AIDS has had an effect of further stig matizing homosexuals. This relationship may be due to the view that they put themse lves at risk of contracting HIV infection through high-risk sexual behavior (Katz, et al., 1987). Their research, although conducted in the 1980s, supported the fact that stigmatization associated with AIDS brings out the disdain in h ealth care professionals as we ll as in the general public. Alternately, second year medical students at a large Midweste rn university were significantly more tolerant to ward AIDS patients if they had homosexual and/or HIV+ friends (Kopacz, Grossman, & Klamen, 1999).

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76 Intentions Concern exists about dentists reluctance to treat HIV+ patients. Efforts have been made to document the extent of their re luctance, and to contemplate the factors that influence it. Some factors have been documented that contri bute to the variations in dentists reported willingness to treat patients with HIV/AIDS. These factors include but are not limited to: homophobia, stage of disease, and treatment location. Homophobia is seen in a California study of dentists that found that 70% agreed that dental personnel had a responsibility to treat AIDS patients, although 63% of them reported that they would not want to treat homosexual male s, intravenous drug users or hemophiliacs (Gerbert, 1987). Breault and Proli froni (1992) also repo rted discomfort and reluctance about coming in contact with HI V+ patients due to harboring a negative attitude towards homosexuality and intravenous drug users, and fear of contracting the virus. One study of Chicago dentists found that 68% would be willing to treat asymptomatic HIV+ patients (Moretti, Ayer & Derefinko, 1989), but another Chicago study one year later indicate d that 73% of dentists w ould not knowingly treat HIV+ persons (Rydman, Yale, Mullner, Whitels & Banx, 1990). That same study showed that fewer respondents would treat symptomatic pati ents of record with AIDS (19%), than asymptomatic AIDS patients of record ( 24%), and fewer dentists would treat new patients than patients of record. These dentists also believed that a special clinic outside of their private pract ices should be established for patients with AIDS, and some respondents saw the need to establish a specia lty clinic within th eir own practice for HIV+ patients. Another national study found th at 60% of dentists were willing to treat HIV+ patients, but only 29% agreed that pr ivate practice was an acceptable location to

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77 treat them (Sadowsky & Kunzel, 1991). Thes e perspectives toward practice were strong predictors of dentists willingness to treat pa tients with HIV/AIDS. A survey of AsianAmerican and non-Hispanic/Caucasian-American dentists who practiced in New York City revealed that Asian dentists expresse d significantly more negative attitudes, and more unwillingness to treat HIV+ patients than did White dentists (Raphael, Kunzel & Sadowsky, 1996). It also showed that Asian de ntists schooled outside of the U.S. held more negative attitudes than those who had been schooled within the U.S. Acculturation may have an impact on access to oral h ealth care among HIV+ persons as AsianAmerican dentists become increasingly represented among pract icing dentists in the U.S. Researchers found an increased willingness by dentists in private practice to treat HIV+ patients (Sadowsky & Kunzel, 1994). Two national surveys conducted in 1986 and 1988 reported an increase from 21% to 31% respectively (Verrusio, Neidle, Nash, Silverman, Horowitz, & Wagner, 1989). Similarly, surveys of Minnesota dentists showed that 23% were willing to treat AIDS patients in 1986, and th at increased to 38% one year later (DiAngele s, Martens, Little, & Hastreiter, 1989). A study was conducted to understand the inte ntion of dentists in Quebec province to provide clinical care to HIV/AIDS patients (Godin, Naccache, Brodeur, & Alary, 1999). Overall, dentists had a st rong intention to provide clin ical care to these patients. However, 25% of the respondents indicated a low intention to provide dental care to them. The main factors explaining the varian ce in intention were perceived behavioral control, personal normative belief, and habit of treating patients with HIV/AIDS. McCarthy, Koval, MacDonald and John (1999) found that the best predictors of willingness to treat patients with HIV we re younger age (less than 30 years), attending

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78 continuing education on HIV/AIDS in the past two years, practicing in small population centers (under 10,000), and gender (male). A nother study of private general practice dentists in New York City looking at predic tors of willingness to treat HIV-infected patients revealed that the influence of pract ice viability was a statistically significant predictor for men, whereas informal and form al collegial norms were more influential predictors for solo female practitione rs (Kunzel, Sadowsky & Tseng, 1997). Quartey (1998) found a strong positive correlation between having ever treated an HIV+ patient, and willingness to treat HI V/AIDS patients. McCarthy, Koval and MacDonald (1999) found that the best predictors of refusa l to treat patients with HIV/AIDS were lack of ethical responsibil ity, fear of cross infection and lack of knowledge of HIV. Another st udy by these researchers identifie d the best predictors of dentists refusal to treat patients with HIV were older age (over 60 years), and practicing in population-dense centers (> 500,000) areas (McCarthy, Koval MacDonald & John, 1999). Other researchers (Jemmott, Je mmott III & Cruz-Collins, 1992) found that nursing students who had less knowledge of AIDS and who perceived greater occupational risk of HIV infection expressed stronger intentions to avoid caring for AIDS patients. Unwillingness / Refusal to Treat There are many reasons why dentists are afraid of, or disdain people with HIVinfection (Glick & Burris, 1997). They may f ear occupational transmission or social contamination, loss of business, or they may not agree with the lifestyles of some HIV+ persons. Burris (1996) inves tigated the causes of this discrimination, and found that

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79 knowledge alone did not change dentists unwil lingness to treat. Their results also emphasized the influence on dentists behavior of professional norms. McCarthy et al (1999) found that the strongest predictor of refusal to trea t patients with HIV/AIDS was lack of ethical responsibility. Gerbert, Badner and Maguire (1988) found that 45% of dentists surveyed felt that fully complying with infection control proced ures was a financial burden, and therefore, 70% of them preferred to refe r both persons at risk for, and those with AIDS to other DHCPs for care, even though 65% believed that they had a responsibility to treat such patients. It is important to note that th is study was conducted before infection control procedures were mandated legislatively. Grace and Cohen (1993) showed that th ere were no differences among oral surgeons, general dentists and periodontists when asked if they were unwilling to treat AIDS patients. All groups listed the same reasons for not treating AIDS patients: increased personal risk of infection, followed by staff fears of infec tion, and finally, fear of losing patients. The If I treat HIV-infected patients my non-infected patients will leave argument is similar to concerns heard from restaurant owners in the era of racial desegregation in America. It is a classic example of a collective action problem, and someone has to be first. If all dentists committed to treating HIV+ patients, no one dentist would suffer (Grace & Cohen, 1993). A survey of critical care nurses showed that if given a c hoice, 45% of those working in a teaching hospital, and 65% of those working in a community hospital would refuse to care for patients with AIDS (D amrosch, Abbey, Warner, & Guy, 1990). Those

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80 nurses who indicated a preference for refusa l showed significantly higher levels of concern and significantly less fa vorable attitudes than the remainder of respondents. Similarly, a study of second year medical st udents at a large Mi dwestern university revealed that one-third believed they had th e right to refuse to treat AIDS patients (Kopacz, Gossman, & Klamen, 1999). McCarthy, Koval and MacDonald (1999) found that the best predic tors of refusal to treat patients with HIV/AIDS were lack of ethical responsibility, f ear of cross infection and lack of knowledge of HIV. Another study by these res earchers identified the best predictors of refusal treat patients with HIV were older age (over 60 years), and practicing in population cente rs with more than 500,000 population (McCarthy, Koval MacDonald & John, 1999). Other research ers (Jemmott, Jemmott III & Cruz-Collins, 1992) found that nursing students who had le ss knowledge of AIDS and who perceived greater occupational risk of HIV infection expr essed stronger intenti ons to avoid caring for AIDS patients. Researchers found that late responders to their survey were significantly more likely to report that they would refuse to treat any patients with HIV (McCarthy & MacDonald, 1997). A recent study provided insight into why health care providers refused to treat HIV+ patients (S ears & Ho, 2006): 1) some justified their policies by their lack of expertise or medical equipment; 2) they had not treated an HIV+ patient before, or 3) their sta ff were inadequately trained, or would revolt if asked to treat an HIV+ patient.

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81 Behavior The experience of treating HIV-infected patients had a greater impact than knowledge alone in influencing dentists behavior towards HIV/AIDS patients (Quartey, 1998). Results of a study of Texas dentists revealed an inverse relationship between population density and avoidance behavior towards AIDS, and dentists who had practiced more than ten years displayed higher avoidan ce characteristics toward AIDS (Cottone & Dove, 1990). There is little lit erature about actual behavior of dental providers (Glick & Burris, 1997). Dental Care Experiences of HIV+ Individuals One study assessed the experi ences of people living with HIV/AIDS in obtaining and undergoing dental treatment (Terry, Jones, & Brown, 1994). Sevent y-five percent of respondents believed that dental care was important, or very important, and 37% had increased the frequency of thei r dental visits. Seventy-four percent of the participants had disclosed their HIV diagnosis to their dental provider. Of those who had concealed their HIV status, one-third feared rejection by DHCPs. Only three subjects reported denial of treatment on the grounds that they we re HIV+. Interestingl y, almost half of the participants changed dentists after they were diagnosed as HIV+. The main reasons for these changes included cost of care, and fear of breach of confidentiality. Another study assessed the experiences of people livi ng with HIV/AIDS (n=57) in Aotearoa, New Zealand in obtaining and undergoing dental treatment (Terry, Jones, & Brown, 1994). The majority of respondents were gay white males. Seventy-four percent of participants had disclose d their diagnosis to their DHCP and had experienced either

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82 supportive or sympathetic reactions. Of those who had not disclosed, only three people reported denial of treatment on the grounds of their HIV status, and another two people were referred by their pract itioner after disclosure. A professional colleague discussed his e xperiences with being diagnosed and a subsequent dental visit. Bo th experiences revealed stigma and discrimination by health care providers. Jim was working as a truc k mechanic in 1993 when he hurt his back while lifting an engine. The back problems we re painful, and he had three bulging discs. Simultaneously Jim began to experience high fevers, weight loss, and thrush in his mouth. Primary care doctors we re unable to relate the symptoms to the back problems, and they referred him to specialists. Fina lly, after loosing more than 30 pounds and thinking he was going to die, he was referred to an oncologi st, who ran all the necessary tests for cancer. Once again, the diagnosis wa s negative. So the doctor tested him for HIV, and Jim returned for the results. The oncologist walked into the office and said to him: So, why are you so bad? I go to me dical school, raise my children, and live a good life. YOU have AIDS! Because of the thrush, the oncologist recommended that he see a dentist. He made the appointment with a dentist who was listed as a provider on his wifes new dental plan. Jim went to the appointment and checked yes next to HIV/AIDS on the health histor y. When he told the dentist he was HIV+, there was a noticeable change in the dentists attitude. In fact, no one asked him questions, but many staff members came into the operatory to look at him. He said he felt like he was a spectacle. The dental hygienist cleaned his teeth, and did not use universal precautions, even though Jim told her to use them. Upon walking out of the operatory, Jim saw HIV+ written in four-inch red letters on the front of his chart. Next Jim went to a case

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83 management agency where a case manager was assigned to help him negotiate the health care system. He discussed the dental visit with the case manager who agreed with his assessment. Jim called the dental office, and complained to the dentist about the disrespectful behavior during his office visit. The dentist called him back to inform him that he would be re-evaluating the office policies. Jim did not return to that dental office (personal communication, April, 2006). Theoretical Framework A theory is a set of interrelated propositions containing concepts that describe, explain, predict, or control behavior (Glanz et al. 1990). Theories (conceptual frameworks) are useful because they enhance, info rm, and complement the practical technologies of health education. Value expectancy theory provides a framework for methodologically evaluating the issues a person may consider in deciding whether or not to take a specific course of action. Value expectancy theories such as the Health Belief Model (HBM) and the Theory of Reasoned Action, also considered to be a grounded theory, have evolved over the past 30+ years during which time consid erable progress was ma de in understanding what determines individuals health-related behaviors and methods of stimulating their positive behavior changes. The theoretical framework for this study is the Theory of Reasoned Action (TRA) (Fishbein, 1967; Fishbein & Ajzen, 1975; Aj zen & Fishbein, 1980). The TRA focuses on individual motivation to determine the role of someone engaging in a specific behavior (Fishbein & Middlestadt, 1989). Ajzen and Fishbeins Theo ry of Reasoned Action is a

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84 highly developed behavioral theory (Gla nz et al. 1990). The TRA proposes that behavioral intentions and asso ciated behaviors result from a rational process. The focus of this theory is on the attitudes, beliefs, and intentions regarding the proposed behavior. This model assumes that behavioral intention is the immediate precursor that determines behavior, and all other factors th at influence behavior are medi ated through that intention. The measurements of intention and behavior must closely correspond with each other in terms of the action, target, context and time to predict behavior accurately. The Theory of Reasoned Action has been used more recently by AIDS researchers to develop interventions that help people at high risk to lower their risk of c ontracting HIV infection (Morrison, Baker & Gillmore, 1998; Norris & Fo rd, 1995). For example in this proposed study, if the action of interest is treating patients with HIV/AI DS, intention to treat that specific population should be assessed among dental hygienists. The target population is patients with HIV/AIDS; context applies to the place where the action takes place (clinic, private office, hospital), and time (day, afte rnoon, evening, weekend or holiday) is the timing of the action. A graphic summary of the Theory of Reasoned Action is shown in Figure 2.2.

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85 Figure 2.2. Theory of Reasoned Action The Health Belief Model lends itself to the Theory of Reasoned Action. Four central beliefs are thought to influence behavior in the Health Belief Model: (1) an individuals perception of their personal susceptibility to a di sease; (2) the actual severity of the disease or persons condition; (3) the perceived effectiveness of the behavior in dealing with the condition, and (4) ones perceived barriers to adopting the behavior. These four beliefs, combined with the affectiv e domain of attitude, are incorporated into the Theory of Reasoned Action (C oreil, Bryant & Henderson, 2001). In 1988, Rosenstock, et al, proposed that self-efficacy be added as a separate independent variable to the HBM constructs of perceived to more fully account for health-related behavior. Efficacy expectation is defined as the confidence that one can successfully perform the behavior required to produce the outc omes, and is distinct from outcome expectation which is defined as ones estimate that a given behavior will lead to certain outcomes. Therefore, it is important to show this distinction since both are required for behavior. The or iginal HBM was limited to simple preventive actions such Beliefs and Evaluations of Behavioral Outcomes Attitude toward the Behavior Normative Beliefs Subjective Norm Behavioral Intention Behavior Source: Ajzen & Fishbein, 1980, p.8.

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86 as getting an immunization, however, the si tuation is different when working with chronic illness, particularly when long-term change is require d. This requires a great deal of confidence that a person can alter their lifestyle before successful intervention is possible. The following diagram shows this relationship: PERSON BEHAVIOR OUTCOME Efficacy Outcome Expectations Expectations For example, for a dental hygienist (PERSO N) to treat HIV/AIDS patients (BEHAVIOR) and not become infected with HIV (OUTCOME), he/she must believe both that treating HIV/AIDS patients will not harm his/her health (OUT COME EXPECTATION) and also that he/she is capable of treating HIV/ AIDS patients (EFFICACY EXPECTATION). And this takes us directly to the Theory of Reasoned Action. According to the Theory of Reasoned Ac tion, attitudes are a function of beliefs, and the beliefs that underlie a persons at titude toward the behavior are termed behavioral beliefs An individuals positive or negative evaluation of performing the behavior is termed attitude toward the behavior (Azjen & Fishbein, 1980; Dunkle & Hyde, 1995). Attitude is defined as the tendency to r eact positively or negatively to a person, object or situation (Coreil, Bryant & Henderson, 2001). Ones attitudes have a great influence over their beha vior. When it comes to heal th behaviors, attitudes are strongly related to consequences. How someone feels about adopting a health behavior is linked to ones perception of th e outcome. For example, if one perceives the outcome to be positive, then performing the health beha vior will create positive attitudes. On the

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87 other hand, the more barriers one expects, th e more likely that person will develop negative attitudes, and no t adopt the behavior. The beliefs underlying a person s subjective norm are called normative beliefs Normative beliefs are the persons beliefs that specific individuals or groups think he/she should or should not perform the behavior. Thus, the subjective norm may exert pressure to perform or to not perform a given behavi or, independent of the persons own attitude toward the behavior. Figure 2.3 summari zes the discussion and operationalizes the variables around the theo retical constructs. Figure 2.3. Factors Determining Ones Be havior and Survey Item Categories A persons beliefs that the behavior leads to certain outcomes and his / her evaluations of these outcomes SELF 8-17, RISK 18-21 ATT 22-24,27,29,3031 34 Attitude toward the Behavior A persons beliefs that specific individuals / groups think he / she should or should not perform the behavior and his / her motivation to comply with the specific referents NORM 25-26,28,31-33 Subjective Norm Intention INT 1-7 Behavior Source: Ajzen & Fishbein, 1980, p.8. Relative importance of attitudes and normative considerations

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88 Figure 2.4. Theories of Reasone d Action/Planned Behavior The relationship between inten tions and health behavior ha s shown varied results. Researchers (Rise, Astrom & Sutton, 1998) studi ed adolescents use of dental floss and found that subjects in the intenders group were more likely to flo ss their teeth, because they believed it would result in positive outcomes. Chan and Heaney (1997) found that workers who intended to participate in a wo rksite smoking cessation program were more likely to attend the education sessions than those workers who had not stated their intentions to participate. At the same time, stress levels of these workers mediated this relationship. For example, workers who belie ved their jobs to be highly stressful were Behavioral Beliefs Attitude toward the Behavior Normative Beliefs Subjective Norm Behavioral Intention Behavior Source: Glanz et al, 2002, p.68. Note: Shaded portion shows the Theory of R easoned Action; the entire figure shows the Theory of Planned Behavior. Perceived Power Perceived Behavioral Control Motivation to Comply Evaluations of Behavioral Outcomes Behavioral Beliefs Control Beliefs

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89 more likely to think that they needed to participate in the smoking cessation program. Alternately, Wambach (1997) studied pregnant womens intentions to breastfeed, and found that the womens pre-delivery intentions were not correlated to their postpartum behavior, especially in first time mothers. Another study (Baker, 1988) showed that the two predictor variables (attitude toward th e behavior, and perceived norm of other important persons) significantly predicted part icipants intentions to use condoms with steady, and with new or in frequent partners. The Theory of Planned Behavior (TPB ; Figure 2.4) was developed by Ajzen (1985) in an attempt to expand the applicability of the TRA to situations where behavior is not under a persons willful control (Chatzisarantis, & Biddle, 1998). Intentions and behavioral control are mediated by motivation and ability. Millstein (1996) stated in her study that whereas prior behavi or was the best single predictor of subsequent behavior, small significant associations were detected fo r the full set of TPB constructs. Significant relationships were identified between behavior and percei ved behavioral control and behavioral intentions. This study supports the relevance of the TRA/TPB models for studying the behavior of health care providers. Whereas the TPB is an extension of the TR A, actual behavior of dental hygienists is not being tested in this study, because of Florida Rules and Regul ations governing their direct, indirect and general s upervision by den tists. In other words, dental hygienists in Florida do not have autonomy to treat a pati ent until they are first seen and examined by the dentist who then decides whether or not to treat them. The social normative and attitudinal cons tructs are important factors to examine when attempting to predict the behavioral in tentions of health care providers (Baker,

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90 1988). In two other studies, nurses decisions to provide care for HIV-infected patients were affected by the negative influences of spouses, family members, intimate friends, and religious beliefs (Kerr & Horrocks, 1990; Scherer, Haughey & You-Wu, 1989). Jemmott, Freleicher, and Jemmott (1992) repor ted that nurses w ho were increasingly exposed to persons in AIDS risk groups pe rceived that caring for them increased their risk of contracting HIV infection, despite us ing universal precautions. Nurses who were surveyed regarding their lack of compliance with universal precautions offered a variety of reasons: inadequate AIDS education and su pplies, previous habits, frequent change in CDC and agency directives, and their belief th at transmissibility of HIV was greater than the CDC was willing to admit (Sim inoff, Erlen & Lidz, 1988). Summary On June 5, 1981, the Centers for Diseas e Control and Prevention (CDC) issued the first warning about a rare form of pneumonia among gay men that was later found to be related to AIDS. The epidemic has now become a pandemic of previously unknown proportions, and has taken its to ll on our nation, and more specifically Florida. Florida ranks third in the nation for adult and adoles cent cases of AIDS, and second in the nation for confidential name-based reporting of newly diagnosed HIV infection. Racial and ethnic disparities, poverty and disabilities are apparent among HI V/AIDS populations. There has been a relative dearth of atte ntion paid by health care planners and policy makers to dental health issues, desp ite the important relationships established among oral health, nutrition and general health. Oral health care conditions associated with HIV disease are frequently more severe than those of the ge neral population, making

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91 access to both dental and medical care im perative. Two HIV Costs and Services Utilization Studies (HCSUS) of unmet need fo r oral health treatment in HIV+ patients revealed a dramatic increase in unmet need for dental services from 2001-2005. The significance of these studies is evident when one considers the scarcity of dental health care professionals that have been willing to treat persons with HIV/ AIDS over the last 25 years. Better data of this kind may im prove understanding and estimating problems of clinically treating pers ons with HIV/AIDS. This study is being proposed for the following reasons: Persons with HIV/AIDS are in need of dental services; There has been little change in the dearth of dental professionals who have been willing to treat persons with HIV/AIDS; Nationally, dental hygienists continue to report their fear of contracting HIV occupationally; Findings may show that changes or additi ons to the pre-professional training and continuing education requirements of dental hygienists are warranted.

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92 Chapter III Methods Purpose of the Study The purpose of this study was to examine th e attitudes of curren tly licensed dental hygienists in Florida with respect to providing dental treatment to HIV-positive persons. Intentions to treat HIV-positive patients were explored, as intention is an indicator of probable behavior. Dental health care profe ssionals awareness of access to dental care by HIV/AIDS patients has been an ongoing issue. Better data of th is type may improve understanding and estimating problems of access to oral health care for the HIV-positive population. Objectives of the Study This study had several objectives. In cluded among these objectives was the intention to: Describe the demographic pr ofile of dental hygienists who respond to the survey; Measure the attitudes, self efficacy, risk of becoming HIV-infected, normative beliefs, and intentions among respondents as related to treating persons with HIV/AIDS; Make recommendations to dental professionals about how to work effectively with HIV/AIDS patients.

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93 Conducting this study may ultimately shed light on improving access to care, thereby helping to reduce oral health disparitie s for HIV/AIDS patients in Florida. Research Questions 1. What are dental hygienists stated intentions, attitude s, perceived risk, perceived self efficacy and normative beliefs toward treating HIV/AIDS patients? 2. What is the association between dental hyg ienists intentions to treat and perceived self efficacy, perceived risk of being infected, attitudes and normative beliefs toward treating HIV/AIDS patients? 3. Is there an association between Years in Practice, and intention to treat HIV/AIDS patients? 4. Is there an association between Ever Tr eated an HIV+ Patient as a Student, and intention to treat HIV/AIDS patients? 5. Is there an association between Ever Tr eated an HIV+ Patient in Private Practice, and intention to treat HIV/AIDS patients? 6. Is there an association betw een Knowing a friend or family member with HIV/AIDS, and intention to treat HIV/AIDS patients? 7. What is the measure of association between dental hygienists intentions to treat, perceived self efficacy, perceived risk of being infected, and attitudes and normative beliefs about treating HIV/AIDS patients? Study Design This study was descriptive and cross-sectional using quantitative methods to explore the behavioral and norma tive beliefs, attitudes, and in tentions of licensed dental

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94 hygienists to treat patients with HIV/AIDS. Values were assessed using an instrument that was developed from surveys of previous ly validated items (Laschinger & Goldberg, 1993; Preston, Young, Kock & Forti, 1995; Lester, 1989; Kunzel & Sadowsky, 1993), and personally developed items. A 3-phase pilot study was conducted. In Phase 1, the survey was reviewed by a panel of experts who were faculty members in the dental hygiene program at the researchers alma mater. Phase 2 consisted of second-year dental hygiene students at one local community college who took the survey online, and assessed its appearance and ease of use of the instrument itself. Phase 3 was completed by second-year dental hygiene students at a different community college in Florida, who field tested the survey as a dry run of the actual im plementation of the instrument. These results were used to assess reliability of the survey instrument. The study was conducted using an online em ail questionnaire to survey dental hygienists described previously in the Popul ation and Sample section. The advantages of using a questionnaire format is that it permits anonymity; it allows a person a considerable amount of time to think about his/her response before answering, and it provides uniformity across measurement situ ations (Henerson, Mo rris, & Fitz-Gibbon, 1987). The staff of the Information Services Department within USF HEALTH of the University of South Florida (USF IT Department) set up a blinded format to email the survey to single users, so that other po ssible respondents and non -respondents would not have access to others email addresses. A b linded format also was used to receive data from completed online surveys.

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95 Email surveys provide many efficient elements for conducting surveys, and include almost completely eliminating paper, postage, the labor of mailing, and data entry costs. The main advantage of an email survey is increased speed (Dillman, 2000). Although email surveys are simpler to compose and send, they are more limited in visual stimulation and interaction capabilities comp ared to Web based surveys (Dillman, 2000). Another disadvantage of a Web-based survey is that it is constructed on a Web site for which the participant must have a different software application (Dillman, 2000). For this study, greater complexity items such as ex tensive skip patterns were not used. Also, things like pop-up instructions, and ot her technologically ch allenging marketing techniques were not necessary components fo r conducting this online dissertation survey, therefore, an email format was selected. Only a portion of the American populati on can be contacted via email (Dillman, 2000). Since there were not enough subjects with FDHA email addresses in order to achieve sufficient power for the study, postcards were mailed to the remaining members without email addresses on file, and contained the survey link. Three mailings occurred. The postcards (see Appendix) were mailed on the dates indicated on the timeline for survey dissemination. In addition, not all of the email addresses were current. This limitation meant that it was not possible to list all FDHA members with email addresses and draw a sample for which every dental hygienist had a non zero chance of being selected for the survey. Conducting intern et surveys has been limited to survey populations with high rates of computer use such as businesses, universities, large organizations, groups of professionals, and pe rsons who purchase computer equipment. This survey applied to groups of professionals.

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96 Population and Sample The total number of licensed dental hygien ists in Florida who were members of the Florida Dental Hygienis ts Association as of May, 2007, was 984. Those with email addresses registered with the association was 613 at the time of this survey. The remaining 371 members did not have register ed email addresses on file with FDHA. Current email addresses and mailing labels of licensed dental hygien ists were obtained through the Executive Director of the Flor ida Dental Hygienis ts Association (see agreement in Appendix A). The entire population was surveyed. Just how accurately research and evalua tion questions can be answered depends on the adequacy of the sampling design (S arvela, & McDermott, 1993). The sampling design should consist of the following steps: 1. Carefully defining the population. 2. Selecting a sample from the population. 3. Observing or measuring the variable in the sample. 4. Estimating the variable in the population based on measurements taken in the sample. 5. Stating the accuracy of the estimates. A sample was not selected from the enti re population of dental hygienists with email addresses who were members of the F DHA, due to the population being limited in number. Therefore, the sample of convenien ce was defined as all dental hygienists who were members of the FDHA.

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97 Sampling Bias The sample may have been biased because of: (1) being able to access only those who were members of the state associati on; (2) not selecting a random sample of association members, and (3) members who did not have internet access with a working internet address. There are differences be tween health care profe ssionals who do / do not maintain membership in their national / stat e professional organizations. A recent study found differences between members of the Amer ican Dental Hygienists Association and non-members (King & Muzzin, 2005). That study found that ADHA members were less likely to alter clinical practices when treati ng infectious disease pa tients. The findings also suggested that membership in a prof essional organization may have impacted the attitudes and practices of s ubjects through exposure to cu rrent research in disease transmission. Having greater access to resear ch publications and continuing education programs through local, state and national associations may make members more knowledgeable about infectious disease tran smission, thus decreas ing the likelihood of feeling a need to alter clinical practices. Th ese results may have been biased, and thus it limited inference to the general practicing dent al hygiene population Limitations of the present study were consistent with those f ound in survey research limited to sampling members of professional associa tions. While the instrument was pilot-tested and revised, misinterpretation of questions and a desire by the partic ipant to answer questions correctly could not be controlled. Investigator bias was minimized by usi ng a blinded study design, which kept the respondents data unidentifiabl e to the researcher. The da ta is what it is, and it is

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98 important to be aware not to inject the resear chers personal biases, as it could invalidate the study findings. Levels of Permission Several levels of permission were required to conduct this re search study. These were: 1) IRB application 2) USFs IT/IS Department(s) 3) Florida Dental Hygiene Association 4) University of Minnesota Dental Hygiene Program 5) Hillsborough Community College Dental Hygiene Program 6) St. Petersburg College Dental Hygiene Program 7) Informed consent from study participants Protection of Human Subjects The survey instrument and study proposal were approved by the University of South Floridas Institutiona l Review Board (IRB; see Appendix). Permission was granted as requested which meant that study pa rticipants were prot ected in matters of privacy, confidentiality, protocols, risks and benefits, and informed consent. Other Permissions The University of South Floridas De partment of Informational Technology and/or the Department of Information Servi ces (USF IT/IS) advised the researcher with setting up the online survey, and acted as the recipient of completed and blinded online surveys. The Executive Director from th e Florida Dental Hygiene Association was

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99 contacted for permission to access the asso ciations database of licensed dental hygienists. Permission was received from F DHA, and those with email addresses were sent the survey (T. Miller, personal communications, 12/ 22/04, 11/28/05, enclosed in Appendix). The Director of the University of Minnesota Dental Hygiene Program was contacted, and gave permission to survey f aculty members for the initial pilot study (K. Newell, personal communication, 11/10/05, enclosed in Appendix). Directors of Dental Hygiene Programs at Hillsborough Community College, and St. Petersburg College were contacted to obtain access to their dental hygiene student populations for pilot study purposes. Permission was received from bot h Directors (T. Grzesikowski, D. SolovanGleason, personal communications, 10/21/05, 10/ 25/05, enclosed in Appendix). Study subjects agreed via informed consent to participate in the online survey. This consent was included in the introductory letter at th e beginning of the online survey. Informed consent was implied when study participants took the online survey. Permissions are included in the Appendix. Selection of Variables Dependent Scale Intention to treat HIV/AIDS patients Independent Scales Attitude toward behavior Perceived risk of occ upational transmission of HIV Self efficacy (ones beliefs in thei r ability toward treating patients with HIV/AIDS)

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100 Normative beliefs (ones beliefs th at specific individuals or groups think he/she should or should not perform the behavior) Demographic / Independent Age Gender Marital status Race Education Year of graduation from dental hygiene program # years in practice Practicing full-time; part-time; not practicing Treated HIV/AIDS patients in school Treated HIV/AIDS patients in private practice Know someone who is HIV+ Instrument The instrument was compiled from scales us ed in previous studies, and contained attitude, intention, belief and subjective normative variables and concepts (constructs). The scales/instrument underwent face and conten t validity processes as well as internal consistency reliability testing. Demogra phic variables also were collected. Intention / Willingne ss to Provide Care A 15-item scale was developed for a disse rtation study (Driscoll, 1996) to assess willingness of dental students to treat persons with different diseases and disabilities.

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101 Divided into two groups, the firs t section of five items dealt with treating persons with HIV/AIDS, and the remaining ten items dealt with treating patients with other special health care needs, and in cluded the wheelchair bound, t hose with cerebral palsy, myocardial infarction, mental retardation, and other infectious diseases. These were patients who typically challenged the clinical care routines of dentis ts and their staffs. These items were arranged on a Likert-type scale with endpoints ranging from 1 (strongly disagree ) to 5 (strongly agree ). Low scores indicate low willingness, whereas high scores indicate high willingness. Driscoll (1996) established that Cronbachs alpha corresponding to the five items treating HIV/AIDS patients was .83, and Cronbachs alpha for the other ten items pertaining to special populations was .86. When tested, the five item measure that focused on willingness to treat patients with HIV/AIDS correlated positively and significantly with the ten items that focused on willingness to treat other special needs populations (.63, p=.0001). In addition, this researcher added fi ve items asking respondents of their willingness to treat a person with HIV/AIDS who is either a patient of record, or who is a new patient; one item was developed and was test ed to see if it was related to perceived risk, and the final two items were tested to see if there was an association with the dependent and independent variables. The way items are worded can affect the way respondents express their willingness to treat HIV/AIDS patients. When items are general and non-threatening, respondents often yield to a social desirability factor, that is, they either want to provide the right answer, or the answer that they think most respondents would provide (McDermott, & Sarvela, 1999). For example, specifying patient type s or disease status

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102 can influence someones willingness to treat a patient. The following example relates to the types of health status (asymptomatic vs symptomatic) and patient status (new patient vs patient of record). Partic ipants could be queried about th eir willingness to treat four specific types of HIV+ patients: asymptomatic, HIV+ patient of record ; symptomatic patient of record who has HIV/AIDS; asymptomatic, HIV+ new patient ; symptomatic new patient who has HIV/AIDS Perceived Self Efficacy / Clinical Ability To assess perceived clinical competence, pa rticipants were aske d a series of ten questions (items 8-17) about the clinical management of patients with HIV/AIDS (Driscoll, 1996). The items were arranged on a Likert-type scale with endpoints ranging from 1 (strongly disagree ) to 5 (strongly agree ). Low scores indi cate low perceived competence, whereas high scores indicate hi gh perceived competence. Driscoll (1996) reported Cronbachs alpha for these items wa s .90. These ten items were used verbatim in this study. Dental Hygiene Care Concerns / Perceived Risk This section of the instru ment was taken from the Nu rses Attitudes about AIDS Scale (NAAS) which was developed and psyc hometrically evaluated in the mid 1990s (Preston, Young, Kock & Forti, 1995). Perm ission was requested and received to use this instrument or portions of it (see Appendix B). Six it ems were chosen from the section on Nursing Care Concerns, and nurse s was changed to dental hygienists in one item. Cronbachs alpha for this section of the NAAS was .90.

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103 Of the 273 items developed for inclusion in the NAAS scale, 60 items were selected and pilot tested for face validity, and a purposive sample of 731 working nurses completed the survey. A factor analysis yielded a single homosexuality factor that explained 53% of the variance in the 21 ite ms measured. This subscale was labeled attitudes about people with AIDS, and Cr onbachs alpha coefficient was .96. Two additional subscales were iden tified in the AIDS realm: attitudes about nursing care concerns (12 items; Cronbachs alpha = .83) and attitudes abou t social-professional concerns (8 items; Cronbachs alpha = .72). These subscales explained almost 39% of the variance. Construct and predictive validity also were established. The NAAS has several suggested applications. They are: (1) as a descriptive tool to investigate AIDS-related atti tudes in a variety of nursing populations; (2) as a means of describing models of nursing pr actice behavior related to pe rsons with HIV/AIDS; (3) as a means of predicting practice outcomes relate d to caring for HIV-infected persons in varying nursing populations, particularly the us e of universal precautions; (4) as a needs assessment for educational programs related to HIV/AIDS; and (5) as an evaluative tool to assess changes in attitudes as a result of educational programs. This instrument has been adapted for use with other health care pr oviders such as health educators, social workers and physicians (Preston, Young, Kock & Forti, 1995). The NAAS was readapted for use in this study to query dental hygienists about their perceived risk in becomi ng HIV-infected (items 18-21). These questions were used (1) to investigate AIDS-related attitudes toward risk in dental hygienists; (2) as a means of predicting practice outcomes related to ca ring for HIV-infected persons, and (3) as a needs assessment for educational programs related to HIV/AIDS.

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104 Attitude / Normative Beliefs This section of the survey was composed of 13 items (ATT22-24,27,29,30,34; NORM25-26,28,31-33) from various sources that measured attitude, motivation to comply, subjective norm, and normative beliefs. Items 22-28 were taken from a survey by Laschinger and Goldenberg (1993) to test the Theory of Reasoned Action. The first six items (22-27) are about personal behavioral beliefs of the consequences of caring for HIV+ patients, and are an indirect measure of attitude. Item 28 measures normative beliefs of their percep tions of the expectations of important others for their performing the behavior. Item 29 was taken from a study by Kunzel and Sadowsky (1993) related to beliefs about occupational risk of cont racting HIV infection. Items 30-31 were developed by Lester (1989) for use in his study about attitudes towards AIDS. Item 32 was taken from the NAAS (1995) and is attitude -related. The last two items (33-34) were developed by the researcher of this study. Item 33 relates to attitude, while item 34 relates to perceived risk of being infected. Demographics Eleven demographic variables were id entified to develop a profile of the respondents, and to test their association with th e dependent variable. These variables include age, gender, marital status, race, education, year of graduation from dental hygiene program, current working status, working full-time or part-time, treating patients with HIV/AIDS both in school and in private practice, and knowing someone who has HIV/AIDS.

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105 Power Analysis and Sample Size Cohen (1988) describes the four parameters of statistical inference as: power, significance criterion (a), sample size (n), and effect size (ES). Any of the four parameters can be determined as long as the other three parameters are fixed. A level of .80 is understood to be adequate. The amount of power that is desired for this study is .80, and the significance crit erion is set at .05. Prior to beginning data collection, sample size must be determined to ensure a large enough sample to conduct the propos ed analysis (Munro, 2005). Cohen (1988) provides a formula to determine sample size when given an effect size index, named L The effect size index table is located in Cohen (1988). He de fines a small effect size as an R2 of 0.02, a moderate effect size as an R2 of 0.13, and a large effect size as an R2 of 0.26. The formula is: L (1 R2) N = + + 1 R2 Where N = total sample size L = effect size index = number of independent variables Sample size was computed using Cohens formula (1988), and results follow: 18.1 (1 .02 ) N = + 11 + 1 .02 For a small effect size, 899 de ntal hygienists had to respond. For a medium effect size, 133 de ntal hygienists had to respond. For a large effect size, 64 de ntal hygienists had to respond.

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106 A 91% response rate (899 dental hygienists reply) was needed to realize a small effect size of 0.02. The researcher highly doubted that a small effect size could be achieved with the total number available in the population of FDHA members, but anticipated at least a medium effect size. Pilot Study The importance of conducting a pilot study cannot be understated. A pilot study is conducted in different pha ses to discover any problems with the data collection instruments and procedures, and data analysis procedures (Sarvela & McDermott, 1993). The pilot test is synonymous with dress rehe arsal and ensures that the instrument, procedures, and the technology are of suffic ient quality to proceed with the study. McDermott and Sarvela (1999) agree with S udman and Bradburn ( 1986) who stated If you dont have the resources to pilot test your questionnaire, don t do the study. Meetings were held with staff at the HS C/IS Department to become familiar with the most recent version of the Ultimate Surv eyor software program (Prezza Technologies, Inc., Version 3.0.4, 2005). The Ultimate Surveyor program was used to input the survey into an internet format, and is the survey program supported by HSC/IT Department. The survey instrument was tested for readability level using the SMOG Readability Formula (McDermott & Sarvel a, 1999), and was found to be at a 10th grade reading level. Usually, this reading level would be too high for a general audience. However, dental hygienists have received tr aining in medical terminology, so they cannot be compared with a general audience. Th is reading level was determined to be acceptable for this audience.

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107 Phase 1 of Pilot Testing: External Expert Panel Review The first phase of piloting the survey in strument involved emailing the survey to a panel of ten experts who were faculty members at the Univer sity of Minnesota, School of Dental Hygiene. They were asked to revi ew the online survey a nd provide feedback on clarity, redundancy, appropriate ness, and thoroughness. The questionnaire was revised according to the suggestions by seven expert panel members, that is, wording was changed for clarity, redundant items were deleted, and th ree items were added. By completing this exercise, the number of surv ey items was reduced from 75 to 45 items. Phase 2 of Pilot Testing: Mini-pilot Test Phase 2 (mini-pilot) and Phase 3 (field test) of pilot testing were completed by dental hygiene students, because the population of dental hygienists in the state of Florida who were members of FDHA was limited in num ber, and therefore, the researcher did not want to reduce the pool of available respondents. Convenience samples of dental hygiene students from area dental hygiene pr ograms were surveyed for the pilot study only. Fifteen second-year dental hygiene students from Hillsborough Community College were surveyed during Phase 2 of pilot testing to assess app earance, ease of use of the instrument, and pre-implementation pro cedures. Several suggestions were noted during the mini-pilot test, and these change s were implemented into the survey. Phase 3 of Pilot Testing: Field Testing Phase 3 of the pilot study was conducted at St. Petersburg College, where 33 of 35 second-year dental hygiene students complete d the survey online (94% return rate). Students were on the honor system in taking the survey, so this high of a return rate is considered excellent. This fiel d test served as a dry run of the actual implementation of

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108 the instrument, and was used to assess reliabili ty. The field test is the last chance to identify any problems with the instrument (McDermott & Sarvela, 1999). The three phases of pilot testing were nece ssary to make sure that all problems were solved before the survey was implemented. Reliability and Validity of Instrument How do we know that the data results can be trusted? It is important to assess the reliability and validity of data collection instruments used in a study so that the researcher(s) believe that the resulting data is true. Reliability is concerned with the ability of an instrument to obtain consistent results, whereas validity refers to the ability of an instrument to measure what it purpor ts to measure (McDermott & Sarvela, 1999). Phases 1, 2 and 3 of pilot testing provided the researcher with preliminary data which was used to assess the reliability and validity of the survey instrument. A review by a panel of experts permitted the face validity (the instrument appeared to measure the construct under consideration, and appeared to be appropria te for the audience it was intended) and content validity (the instrument examined all content areas adequately) to be assessed along with other relevant instrument characteristics. Data collected from the pilot subjects allowed for survey restructuri ng and calculation of reliability coefficients. Internal Consistency Reliability In this study, internal consistency re liability was assessed, and examined the average association among items by measuring the degree to which items relate to each other (the degree to which items hang togeth er.) Researchers unders tand that the items on a survey instrument should all be related to each ot her. Measuring internal

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109 consistency reliability produces a coefficient that ranges from a value of 0 (which means that there is no reliability), to 1 (which means perfect relia bility). A minimum value of .60 is desirable for a basic research or ev aluation study, whereas, .80 is the preferred reliability coefficient for applied studies, and above .90 is the preferable measure for studies that involve clinical decision making. The greater the consistency in responses among items, the higher coefficient alpha will be. The logistical advantage of using internal consistency reliability is that the survey is administered once, to one group of subjects (McDermott & Sarvela, 1999). Prior to conducting the reliability analys is, item transformation occurred, where two items (NORM 28R, ATT 30R) were reverse sc ored so that the analyses of the total score that is computed by the reliability pr ocedure is meaningful. Reverse scoring of items occurs when all items on a measure have the same response scale where high scores on some items represent high scores on the construct being measured, whereas high scores on other items repres ent low scores on the same construct. The scores on the latter items were reverse scaled. These t ypes of items are commonly found on attitude scales. For this study, five scales of items plus demographic variables were implemented. Since multiple scales were used, separate in ternal consistency estimates were computed for each scale score (Green, S.B., Salkind, N. J., & Akey, T. M., 2000). The last section consisted of 13 items, seven that measured attitude, and six that measured normative beliefs. The researcher ran reliability tests on the initia l scale (ATT 22-34). Results showed that the reliability coefficient wa s below .60, and therefore the 13 items were

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110 split into two new scales (attitude = ATT 22-24,27,29-30,34; normative beliefs = NORM 25-26,28,31-33). Both scales re liability coefficients we re above the .60 limit. Three assumptions were met that unde rlie estimating internal consistency reliability: 1. Parts of the measure must be equivalent. Every item was assumed to be equivale nt to every other item. All items measured the same underlying dimension per scale. 2. Errors in measurement between parts are unrelated. Respondents were not forced to comple te the scales in an allotted time, nor were any items linked between scales. 3. An item or half test score is a su m of its true and its error scores. Whereas this assumption is necessary for the internal consistency estimate to accurately reflect a sc ales reliability, it is difficult to know if this assumption was violated or not. Internal consistency reliability wa s computed using SPSS 15.0 for Windows (SPSS Inc., 2007). Estimates of Cronbachs Al pha for the five subscales demonstrated preferred reliability coefficients fo r all subscales as shown in Table 3.1. Once the reliability of the survey instrument was established, validity studies were conducted. Validity is the most important i ssue to consider when evaluating a test instrument, because it refers to the qual ity of the data produced from using the instrument. Face validity and content validity of the instrument used in this study were established by the expert panel of dental hygiene faculty members.

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111 Table 3.1 Estimates of Cronbachs Alpha by Subscale Scales Cronbachs Alpha Cronbachs Alpha based on Standardized Items N of Items Item Numbers Intention .926 .945 7 INT 1-7 Self Efficacy .855 .857 10 SELF 8-17 Risk .629 .672 4 RISK 18-21 Attitude .788 .772 7 ATT 22-24,27, 29-30,34 Normative Beliefs .661 .680 6 NORM 25-26, 28,31-33 There are many influences on dental hygienists that could have confounded this study. These influences are financing, market justice versus social justice, crossover effects between general prejudice and HIV, low-income, Medicaid, and a multiple needs population. Financing dental care has become more difficult for people with HIV/AIDS because of the changing face of dental insura nce (increased cost; fewer benefits), and Medicaid eligibility limits that were reduced once again which has put more patients in the category of medically uninsured. Changing the way a person receives care with a different payment and eligibility system can be a daunting task, and some people may decide not to begin a new system of health car e because it seems too difficult at the time. Low income persons may also be unable to afford medical / dental insurance through their employers, and therefor e are uninsured. Also, funding by the federal government for oral health care is not as generous as be fore, and even last pay sources such as Ryan White funds have had to exist on fewer dolla rs when there are more HIV/AIDS patients being identified in need of oral health services. The influence of a multiple needs population decreases the number of providers who are wi lling and/or able to treat them,

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112 and therefore, access to care is affected. Finally, the crossove r effect of general prejudice and HIV is very real, as was shown in the recent study of dental hyg ienists in 13 states (King & Muzzin, 2005), and in other st udies / anecdotes cited within. Survey Administration Just as multiple contacts of respondent s may be necessary for face-to-face interviews, telephone surveys, and mail surv eys, they also are essential for e-mail surveys. An important part of the contacts is the first, or prenotice email message that announces the upcoming survey. The time th at elapses between the prenotice and questionnaire can be shortened to two or th ree days to increase th e likelihood that the respondent will remember that he/she received the prenotice and to connect it to receipt of the actual survey instrument. The purpose of the prenotice is to leave a positive impression of importance so that the respondent will not immediately delete the email survey when it arrives. A plus for email surv eys is that they are returned faster than a paper survey which implies that it may be possible to shorten the normal intervals between contacts of respondents (Dillman, 2000) This procedural fact allows for reducing the lengthy implementation time required for this type of study, and is the least costly of all survey methods. Dillman (2000) proposes up to four contacts for this type of survey a prenotice, the questionnaire, a thank you/reminder, and a replacement questionnaire. To maximize response rates, persons are emailed individually in stead of contacted through a mass emailing. The mass email message that shows many names in the address area or a listserv heading should be avoided, because mail survey research has shown that

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113 personalization is important to achieve repl ies (Dillman, 2000). Th erefore, the email message appeared to be addressed on ly to individual participants. A copy of the timeline to implement th e survey is located in the Appendix. On July 10, 2007, a prenotice email was sent by th e national office of the American Dental Hygienists Association to al l Florida Dental Hygienists Association (FDHA) members who have an email address on file. For A ssociation members without email addresses on file, the first postcard mailing was sent simu ltaneously with the FDHA prenotice. On July 12, the survey was emailed from USF IT Dept. at 7:21am. Immediate returns reported over 100 undeliverable email addresses. This information was documented and forwarded to the USF IT Department which checked all responses for accuracy. In all, there were 114 email addresses that were f ound to be invalid. The researcher found six obvious email errors on the list, was alerted about the deat h of one possible respondent, and reported this and the reasons for the undeliverable addresses to FDHA. The reasons for the bounced emails provided by USF IT Department follows: the accounts either no longer existed, or were incorrect on the list that was provided to me; the recipients mailbox was over quota (space); the recipients refusal to accept email (via a spam blocker). All recipients were re-contacted and were asked to accept the survey email. On July 17 after the first mailing, it was determined that the survey link on the postcard was missing one letter. Postcards were reprinted and were re-mailed immediately, announcing the error.

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114 On July 24, the second group of postcards was mailed to thank those who had taken the survey, and to remind those who had not responded to do so. Similarly, two days later on July 26, the second email surv ey with a thank you/reminder message was sent. The postcard and email also thanked t hose who had already re plied to the survey, and reminded those who had not yet replied to do so. The final contacts were made on August 13 (postcard mailing) and on August 15 (email survey) similar to the previous one. Data collection closed at midnight on 8/31/07. At the end of the data collection period, the re searcher had received 219 responses to the survey, and it was determined that satu ration had been reached, therefore, the final contact was eliminated. These contacts were made when there were no other known major conflicts that could have interfered w ith response rates. For example, emails and mailings would not have been sent if a hurricane was threatening. The response rate for this survey was 22% overall; if the 114 invalid email addresse s were subtracted from the total number of FDHA members (984), the actual response rate was 25%. Missing Data The issue of handling missing data usually occurs when using survey methodologies (Buhi, Goodson, & Neilands, 2008). This phenomenon is known as missingness, and may result from a variety of reasons. Reasons for missingness in this study included the subjects refusal to answer survey items that possibility was indicative of items being too sensitive, skipped ques tions, and computer malfunction. When missingness occurs in continuous or in categoric al variables, researchers have identified these as non-response items.

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115 Whereas 24 records were identified with missing data items in this study, only two records were completely deleted from the data analysis as the majority of the items were left unanswered. The remainder of the 22 records revealed randomness of missing data items and therefore, it was decided to retain these records in the analysis. For example, when missing data item(s) occurred in scale 1, there was no scale score for that person for scale 1. In this way, the researcher was able to analyze the majority of all data submitted, rather than following the SPSS 15.0 guid elines that suggested not to include records with any missing data items. Afte r removing the 2 records with missing data items from the 219 total records, 217 comple te records remained for data analysis. Data Analysis Data were returned to USF HEALTH IS (Health Sciences Center/Information Services) via the internet, where it was saved in a Microsoft Excel file. When the closing date of data collection was reached, HSC/IS forwarded the data to the researcher, files were reviewed for missing data, and they were imported into SPSS (Statistical Program for the Social Sciences, 2007). Data were analyzed using SPSS 15.0 (2007) software to assess variations in attitudes, perceived risk, self efficacy, nor mative beliefs, and intentions of dental hygienists on a number of vari ables. Table 3.2 in the Appe ndix displays the research questions, variables, descripti on of the variables, and proposed data analysis plan. The dependent variable was intention, and the independent variables included the items related to attitude, self efficacy, risk, a nd normative beliefs, and eleven demographic variables. SPSS was used for descriptive data analysis, frequency distributions,

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116 correlations, non-parametric tests, and multiple linear regression tests. The level of significance was set at <0.05. The five constructs in this study are rela ted to the Theory of Reasoned Action and include intention, self-efficacy, perceived risk, attitude and normative beliefs. These constructs were operationalized in the su rvey by grouping items 1-34 according to these five constructs (see Figure 2.3). Reverse scoring of selected items was completed. Summated rating scales for each respondent were calculated according to the five constructs producing five scor es per respondent in addition to the information supplied by the demographic variables. For example, seven items were summed (INT 1 + INT 2 + INT 3 + INT 4 + INT 5 + INT 6 + INT 7) to make up the Intention scale score. A summative rating scale is a group of items that are approximately equal on attitude value where subjects respond in terms of agreement or disagreement. The Likert scale is a form of a summative rating scale, and is the scale used most often to measure attitude (McDermott & Sarvela, 1999). Descriptive Statistics / Non-Parametric Tests Univariate statistical analysis was conducted on all indivi dual variables to describe the data. Frequency distributions, measures of centr al tendency and measures of dispersion were calculated for each of th e items and demographic variables. Nonparametric tests (Spearman correlation, Kruskal-Wallis H, Mann Whitney U), were chosen over parametric testing (t-tests, ANOVA) because the sample size was small; the data was mainly ordinal level; there was no assumption about the distribution of the variable in the population to which we plan to generalize our findings, and the data

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117 retained their original values thus making in terpretation easier. Tests were performed on the available data as outlined in the data analysis plan (see Table 3.2 in Appendix). Table 3.2 (see Appendix) depicts variables 1-34 as ordinal data. When both the criterion and predictor variables are ordinal-level data, or when one variable is an ordinallevel variable and the other is an intervalor ratio-level variable, the Spearman rank-order correlation coefficient is recommended to be used (Hatcher & Stepanski, 1994). Only interval-level and ratio-level data are te sted using the Pearson correlation test, and therefore, the appropriate test for variables in this study, when tested against each other, is the non-parametric test, Spearman correlation. The advantage to using the Spearman rank-order correlation test is that it is a distribution-free te st, which means that it makes no assumption concerning the shape of the dist ribution from which the sample data were drawn (Hatcher & Stepanski, 1994). The limita tion to using Spearman correlation is that it uses ordinal, or ranking level data, and therefore, does not have equal quantitative meaning as interval-level data (Hatcher & Stepanski, 1994). This means that the difference in intention scores between respondent 1 and respondent 2, will not necessarily be the same as the difference in intention scores between respondent 2 and respondent 3. The first seven variables (INT1-INT7) measur ed dental hygienists intentions to treat HIV/AIDS patients, and were tested individually for association with the remaining independent construct variable s (SELF8-17, RISK18-21, ATT22-24,27,29,30,34, NORM25-26,28,31-33). Ten variables (SELF8-17) measured dental hygienists self efficacy, and were tested individually for a ssociation with the remaining variable items (INT1-7, RISK18-21, ATT22-24,27,29,30,34, NORM25-26,28,31-33). Four variables (RISK18-21) measured dental hygienists perc eived risk of occupati onal transmission of

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118 HIV, and were tested individually for asso ciation with the remaining variable items (INT1-7, SELF8-17, ATT22-24,27,29,30,34, NORM25-26,28,31-33). Seven items (ATT22-24,27,29,30,34) measured dental hygienists attitudes toward treating HIV/AIDS patients, and were tested indi vidually for association with the remaining variable items (INT1-7, SELF8-17, RISK18-21, NORM25-26,28,31-33). The remaining six items (NORM25-26,28,31-33) measured dental hygienists normative beliefs, and were tested individually for association with the re maining variable items (INT1-7, SELF8-17, RISK18-21, and ATT22-24,27,29,30,34). The Kruskal-Wallis H test was used for research questions 4 and 5 to compare two or more groups and is analogous to th e parametric test, an alysis of variance (ANOVA). The Mann-Whitney U test was used for research question 6 to compare two groups and is analogous to the parametric t -test (Munro, 2005). Univiariate and bivariate analyses of th e distribution of the dependent variable changed the planned multiple linear regressi on (Table 3.2 in Appendix) to a binary logistic regression for research question 7. Regression Model There are many types of regression analys es in the literature. For example, Munro (2005) stated that multiple linear regression is used extensively by researchers because it allows one to find the best fitting and most parsimonious model to describe the relationship between a depende nt variable and several i ndependent variables. The dependent variable is supposed to be conti nuous-level and must meet the assumptions for this type of analysis.

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119 That was not the case in this study. Rather, the dependent variable was categorical, and did not meet the assumption for normality (see Figure 3.1). The histogram shows that the majority of re sponses were clustered in a few response categories. Because of the abnormal distri bution of the dependent variable, binomial (binary) logistic regression was chosen as the statistical method of choice. Logistic regression has the ability to: 1) predict the dependent variable on the basis of continuous and / or categorical independe nt variables to determine the percent of variance in the dependent variable that is e xplained by the independents; 2) rank the relative importance of the independent variables; 3) assess intera ction effects, and 4) understand the impact of covariate control variables. Logistic regr ession does not assume a linear relationship between the dependent and independent variab les, does not require the variables to be normally distributed, does not assume homos cedasticity, and overall has less stringent requirements as compared with multiple linear regression. Before the regression analysis was conduc ted, univariate (see Tables 4.1 4.7) and bivariate analyses (Table 4.16) were reviewed to iden tify statistically significant dependent and independent variab les; further tests were run on selected variables to help with this identification process. The literature was reviewed again for similar studies to determine whether or not to include certai n independent variables in the regression analysis. The regression model was built according to decisions by the researcher whether or not to include specific va riables in the model. The five scale variables and the demographic variable treated in private practice were included in the regression

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120 analyses, because bivariate analysis and further testing determined them to be statistically significant. Figure 3.1 Distribution of the Dependent Variable Next, the dependent variable was recoded into a dichotomous variable using the median (33; range = 7-35) to divide the tw o groups that were coded (0-33 = lower intention group) and (34-35 = higher intention group). The following logistic regr ession model was tested: Dependent Variable: INT Scale Independent Variables: SELF Scale RISK Scale ATT Scale NORM Scale Treated in Private Practice Results are included in Chapter 4. INT Scale Score 35.00 30.00 25.00 20.00 15.00 Frequency 100 80 60 40 20 0 Mean = 31.26 Std. Dev. = 4.15 N = 208

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121 Chapter IV Results This chapter describes the study participants, their responses to the survey items, and results related to the research questions. In all, 217 responses were received via email, and 2 responses were returned by U.S. mail from participants who requested this mode of response. Of the 219 responses, 217 underwent analysis. As indicated in Chapter 3, to have a medium effect size, 133 usable responses were necessary. Consequently, the return of 217 records easil y achieved that desired end. The level of statistical significance (alpha) was set at .05. The number of responses to the items varied as not all particip ants answered each question. Description of Respondents Descriptive statistics revealed a homogenous pool of respondents. Most respondents were female (96.3%) and White ( 89.4%). Ages ranged from 22 to 80 years ( M =46.46, SD= 11.15). In all, 77.4% were marrie d, 51.2% had earned an Associates Degree, and 30.4% had a Bachelor Degree. Surv ey participants graduated from a dental hygiene program between 1948 and 2007 ( M =1987, SD =13.68), and their total years of practice ranged from 1 to 52 ( M =19.27, SD =13.29). Among respondents, 53.9% practiced full-time, and 32% practiced part -time. Whereas 24.0% reported that they treated HIV/AIDS patients as dental hygiene students, 29.0% said they did not, and

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122 47.0% were unsure if they had. A large propor tion of respondents (80.2%) reported they had treated HIV/AIDS patients in private prac tice. Almost 18% of subjects reported that they had a friend or family member who wa s HIV+ or who had developed AIDS. An iteration of demographic tra its is shown in Table 4.1. Previously, the Theory of Reasoned Acti on (TRA) was applied successfully in a study using predictors and subs equent decisions of physical therapy and nursing students to work with geriatric clients (Dunkle & Hyde, 1995). Results showed that for all students, the factors that infl uenced intention were student attitudes and their subjective norms. In this study, the TRA framework wa s applied to identify dental hygienists behavioral beliefs, self-efficacy, perceived risks, attitudes, subjective norms and intentions toward treating HIV-infected patients. Analytical results for each of the previously identified research questions are shown below.

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123Table 4.1 Demographic Characteristics of Responding Dental Hygienists Characteristic N % Gender Female Male Total 209 8 217 96.3 3.7 100.0 Marital Status Married Living with partner or significant other Separated / Divorced Single, never been married Widowed / Widower Total 168 4 25 14 6 217 77.4 1.8 11.5 6.5 2.8 100.0 Race White (Caucasian) American Indian / Alaskan Native Asian Black (not Hispanic) Hispanic / Latino More than one race Native Hawaiian / Other Pacific Islander Unknown Total 194 1 4 5 8 3 1 1 217 89.4 .5 1.8 2.3 3.7 1.4 .5 .5 100.0 Years of Education Associate Degree (AA,AS) Bachelor Degree (BA,BS) Dental Hygiene Diploma Post Baccalaureate Degree (Masters or higher degree) Total 111 66 14 26 217 51.2 30.4 6.5 12.0 100.0 Currently Practicing Full-time Part-time Not practicing Total 117 70 30 217 53.9 32.3 13.8 100.0 Treated as Student Yes No Dont Know Total 52 63 102 217 24.0 29.0 47.0 100.0 Treated in Private Practice Yes No Dont Know Total 174 9 34 217 80.2 4.1 15.7 100.0 Friend / family member who has HIV/AIDS Yes No Total 38 179 217 17.5 82.5 100.0

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124 Research Question 1: What are dental hygienists stated intentions, attitudes, perceived risk, perceived self-efficacy and normative beliefs toward treating HIV/AIDS patients? Descriptive statistics were generated for the 34 items that measured the TRA constructs. Results are shown by construct in Tables 4.2 through 4.6. Table 4.2 Dental Hygienists Intentions to Treat HIV/AIDS Patients (INT Scale) Item Number / Item N Min. Max. Mean Std. Dev. INT 1: I would be willing to provide dental hygiene care for a pers on with HIV/AIDS 216 1 5 4.51 .647 INT 2: I would be willing to provide dental hygiene care for a patient of record with HIV/AIDS 217 1 5 4.55 .615 INT 3: I would be willing to provide dental hygiene care for a new patient with HIV/AIDS 212 1 5 4.50 .685 INT 4: I would be willing to provide dental hygiene care if a patient told me he/she was bisexual 215 2 5 4.67 .519 INT 5: I would be interested in an opportunity to treat patients with HIV/AIDS in my current work setting 216 1 5 3.97 1.110 INT 6: I would take care of any patients with Hepatitis B 216 1 5 4.58 .589 INT 7: I would take care of any patients with Hepatitis C 217 1 5 4.53 .616 Descriptive statistics were generated for the ten items that measured dental hygienists self-efficacy with re spect to treating patients with HIV infection. Results are shown in Table 4.3.

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125Table 4.3 Dental Hygienists Self-Efficacy for Treating HIV/AIDS Patients (SELF Scale) Item Number / Item N Min. Max. Mean Std. Dev. SELF 8: I can identify oral lesions associated with HIV disease 216 2 5 3.98 .705 SELF 9: I know the treatments for common HIV-related oral lesions 217 1 5 3.57 .825 SELF 10: I know community resources for people with HIV disease 215 1 5 3.57 1.014 SELF 11: I can obtain a thorough medical history including HIV risk factors 217 1 5 4.06 .900 SELF 12: I can provide HIV risk-reduction counseling 214 1 5 3.56 1.045 SELF 13: I use universal precautions 216 4 5 4.89 .315 SELF 14: I feel professionally pre-pared to educate patients about HIV disease (e.g. HIV transmission, HIV antibody testing, infection control protocol) 216 1 5 3.93 .988 SELF 15: I can safely provide dental hygiene care to persons with HIV disease 216 2 5 4.59 .546 SELF 16: I know the CDCs recommendations for protocol after an occupational exposure to HIV 217 2 5 4.37 .710 SELF 17: I can effectively provide dental hygiene care to persons with HIV disease 217 2 5 4.51 .624 Descriptive statistics were generated for th e four items that measured the extent of dental hygienists perceived ri sk in treating patients with HIV/AIDS. Results are shown in Table 4.4. Table 4.4 Dental Hygienists Perceived Risk in Treating HIV/AIDS Patients (RISK Scale) Item Number / Item N Min. Max. Mean Std. Dev. RISK 18: I feel worried about the possibility of acquiring HIV/AIDS from patients 216 1 5 2.17 1.155 RISK 19: I worry about possible casual contact with a person with HIV/AIDS 216 1 5 1.49 .759 RISK 20: I feel that dental hygienists need to know the HIV antibody status of patients they are caring for 216 1 5 3.56 1.260 RISK 21: I worry that the infection control procedures used in our office will not protect me from acquiring HIV/AIDS on the job 214 1 5 1.61 .766

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126 Descriptive statistics were generated for the seven items that measured dental hygienists behavioral beliefs and attitudes to ward treating HIV/AIDS patients. Results are shown in Table 4.5. Table 4.5 Dental Hygienists Attitudes and Behavioral Beliefs toward Treating HIV/AIDS Patients (ATT Scale) Item Number / Item N Min. Max. Mean Std. Dev. ATT 22: I would be putting myself at risk if I treated HIV/AIDS patients 217 1 5 2.14 1.190 ATT 23: I would be putting other patients at risk if I work with HIV/AIDS patients 217 1 5 1.73 .899 ATT 24: I would be putting my family at risk if I work with HIV/AIDS patients 215 1 5 1.79 .951 ATT 27: I would hurt my future job prospects if I work with HIV/AIDS patients 217 2 5 1.58 .779 ATT 29: I would prefer not to treat homosexual patients because I am concerned about getting HIV and developing AIDS 217 1 5 1.41 .675 ATT 30*: I would shake hands with someone who has HIV/AIDS 212 1 5 1.44 .815 ATT 34: I feel that I am at risk of contracting HIV due to personal lifestyle practices 217 1 5 1.24 .627 reverse coded item Descriptive statistics were generated for the six items that measured dental hygienists normative beliefs toward treating HI V/AIDS patients. Results are shown in Table 4.6.

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127Table 4.6 Dental Hygienists Normative Beliefs toward Treating HIV/AIDS Patients (NORM Scale) Item Number / Item N Min. Max. Mean Std. Dev. NORM 25: The attitude of my family affects my decision to work with HIV/AIDS patients 217 1 5 1.85 1.009 NORM 26: The attitude of my friends affects my decision to work with HIV/AIDS patients 216 1 5 1.63 .801 NORM 28*: My boss thinks that I should provide dental hygiene care for any person who has HIV/AIDS 214 1 5 2.15 1.055 NORM 31: People with HIV/AIDS should not be allowed to work as dentists or dental hygienists 216 1 5 2.42 1.167 NORM 32: Dental hygienists should be allowed to refuse to provide care to persons with HIV/AIDS 216 1 5 2.18 1.238 NORM 33: My co-workers do not want to treat HIV/AIDS patients 213 1 5 2.55 1.002 reverse coded item Research Question 2: What is the association between dental hygienists intentions to treat and perceived self-efficac y, perceived risk of being infected, normative beliefs, and attitudes toward treating HIV/AIDS patients? Thirty-four variables were split into five summative rating scales and were used to test the constructs of inte rest pertinent to the Theory of Reasoned Action. These constructs were: behavioral beliefs, normativ e beliefs, attitude toward the behavior, subjective norm, and behavioral intention. Five new summative sc ale variables were computed: Intention scale, Self-Efficacy scale, Risk scale, Attitude scale and Normative Beliefs scale. Table 4.7 shows the number of dental hygienists who answered all of the items for each scale, the minimum and maximu m range of scores, the mean and standard deviation of the summative scale scores, and the Cronbachs alpha coefficient for each of the summative scales. The selection of items included in computing the scale scores was based on internal consistency analysis of the se ts of items used to measure each construct

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128 (Cronbachs alpha .60). As shown, the Cronbachs alpha coefficients were moderate to high for all five scales. Table 4.7 Univariate Analysis of Five Constructs Used to Asse ss Dental Hygienists Future Intentions to Treat HIV/AIDS Patients Item N Minimum Maximum Sample Mean Std. Deviation Cronbachs Alpha Coefficient Intention (INT) Scale Score 208 13 35 31.26 4.15 .926 Self Efficacy (SELF) Scale Scor e 208 21 50 40.88 5.23 .855 Risk of Occupational Transmission (RISK) Scale Score 214 4 20 8.80 2.78 .629 Attitude (ATT) Scale Score 210 7 27 11.34 4.05 .788 Normative Beliefs (NORM) Scale Score 210 6 30 12.75 3.85 .661 Descriptive statistics were computed for th e five scale variables and revealed that the Intention Scale showed a significant amount of skewne ss and kurtosis. When the numerical value for skewness (-1.030) was comp ared with twice the Standard Error of Skewness (.169 2 = .338), it was concluded that the distribution was significantly negatively skewed. The same numerical pr ocess was used to determine whether the kurtosis was significantly non-normal. The Standard Error of Kurtosis was multiplied by 2 (.336 2 = .672) to calculate the normal ra nge for kurtosis. Th e numerical value for kurtosis was 1.258, and it was concluded that th e distribution was signi ficantly kurtotic. However, if a distribution is determined to be markedly skewed, there is no need to examine kurtosis because the distribution is not normal (Munro, 2005). A histogram revealed a bimodal distribution for this scale variable. Next, Spearman rank-order correlation test s were conducted on the Intention scale (dependent variable) and the f our other construct scales. Co rrelational tests were used to study the strength and direction of relationships between pairs of variables, and range in

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129 value from +1 to -1, where 0 means that th ere is no relationship between the variables (McDermott, & Sarvela, 1999). Results revealed several statistically significant positive and negative correlations (see Table 4.8). Table 4.8 Intention Scale Scores by Other Scale Scores Value N Approximate Statistical Significance INT Scale SELF Scale .495 201 .000 INT Scale RISK Scale -.381 206 .000 INT Scale ATT Scale -.621 201 .000 INT Scale NORM Scale -.615 201 .000 Research Question 3: Is there an association between y ears in practice and intention to treat HIV/AIDS patients? A Spearman rank-order correlation test was carried out to determine if an association existed between the demographic variable, years in practice and the Intention Scale score. Because years in prac tice constituted an in terval level variable, and the Intention scale repr esented ordinal data, the Sp earman rank-order correlation statistic was used. Results revealed no stat istically significant co rrelation between these two variables (Table 4.9). Table 4.9 Association between Intention Scale Score and Dental Hygienists Years in Practice Value N Approximate Statistical Significance INT Scale Years in Pr actice -.014 202 .841

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130 Research Question 4: Is there an association between having ever treated an HIV+ patient as a student, and future intent ion to treat HIV/AIDS patients? A Kruskal-Wallis H test was used to determine if the nominal variable, ever treated as a student was associ ated with the Intention Scale score. The Kruskal-Wallis H test is the non-parametric analog of the one -way analysis of variance, and was used because it compared two or more groups, and because the INT Scale score violated the assumption underlying the parametric test for normal distribution. Table 4.10 shows that there was no significant correlation between these two variables. Table 4.10 Correlation of Intention Scale Scores with History of Having Treated HIV/AIDS Patients as a Student Did you treat HIV/AIDS patients as a dental hygiene student? N Mean Rank Chi Square Degrees of Freedom Asymptotic Statistical Significance INT Scale Score No 57 91.11 4.277 2 .118 Yes 51 111.64 Don't Know 100 108.49 Total 208 A decision was made to transform the independ ent variable into two categories where the No and Dont Know groups were combined. Further analysis of the Yes and No groups using the Mann Whitney U test confirme d that there was no significant correlation between the two groups, as is seen in Table 4.11.

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131Table 4.11 Recoded Variable: Correlation of Intention Scale Scores with History of Having Treated HIV/AIDS Patients as a Student Did you treat HIV/AIDS patients as a dental hygiene student? N Mean Rank Sum of Ranks MannWhitney U Asymptotic Statistical Significance (2-tailed) INT Scale Score No 157 102.18 16042.50 3639.500 .312 Yes 51 111.64 5693.50 Total 208 Research Question 5: Is there an association between ev er treated an HIV+ patient in private practice and intention to treat HIV/AIDS patients? A Kruskal-Wallis H test determined if the nominal level variable, ever treated in private practice, was associated with future intentions to treat HIV/AIDS patients. The Kruskal-Wallis H test is the non-parametric an alog of the one-way analysis of variance, and was used because it compared two or mo re groups, and because the INT Scale score violated the assumption underlying the parame tric test for normal distribution. Table 4.12 shows that there was a st atistically signifi cant association between these two variables. Table 4.12 Correlation between Intention Scale Scores and History of Having Treated HIV/AIDS Patients in Private Practice Have you treated HIV/AIDS patients in private practice? N Mean Rank Chi Square Degrees of Freedom Asymptotic Statistical Significance INT Scale Score No 8 63.88 15.234 2 .000 Yes 166 112.33 Don't Know 34 75.84 Total 208

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132 The three response options enabled three possible pairs to be examined. Further analysis of the three pairwise comparisons (yes / no; yes / don t know; no / dont know) using the Mann-Whitney U test revealed one st atistically significan t association (yes / dont know; p<0.001) after making the Bonferroni ad justment for multiple comparisons resulting in a more conservative st atistical significance criterion (.05 / 3 p =.017). Because three pairwise comparisons were ma de, there was a chance of making a Type I error, and that is why th e Bonferroni adjustment was made. The new level of significance was now .017 instead of .05. Results in Table 4.13 show the relevant values. After testing the pairwise comparisons, this variable remained statistically significant ( p<.001). Because only 8 respondents re ported not having treated HIV/AIDS patients in private practice, a decision was made to transform the variable by collapsing two categories, no and dont know into a single no category. Thus, the recoded Table 4.13 Pairwise Comparisons: Correlation of Intention Scale Scores with History of Having Treated HIV/AIDS Patients in Private Practice Have you treated HIV/AIDS patients in private practice? N Mean Rank Sum of Ranks MannWhitney U Asymptotic Statistical Significance (2-tailed) INT Scale Score No Yes Total 8 166 174 48.38 89.39 387.00 14838.00 351.000 .018 INT Scale Score Yes Dont Know Total 166 34 200 106.44 71.49 17669.50 2430.50 1835.500 .001* INT Scale Score No 8 20.00 160.00 124.000 .698 Dont Know 34 21.85 743.00 Total 42

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133* p<.017 variable had two response options, yes and no. A Mann-Whitney U test was conducted to determine if the variable transf ormation had any effect. Results showed that there was a significant difference betw een those who have, and those who have not treated patients in private practice, and th eir intention to treat HIV/AIDS patients ( p<0.000). Results are shown in Table 4.14. Table 4.14 Recoded Variable: Correlation of Intention Scale Scores with History of Having Treated HIV/AIDS Patients in Private Practice Have you treated HIV/AIDS patients in private practice? N Mean Rank Sum of Ranks MannWhitney U Asymptotic Statistical Significance (2-tailed) INT Scale Score No 42 73.56 3089.50 2186.500 .000 Yes 166 112.33 18646.50 Total 208 An odds ratio is the probability of some thing occurring over the probability of it not occurring. However, an odds ratio (O R) and confidence intervals could not be computed because 24 (70.6%) of the cells ha d counts <5. The minimum expected count is 20. If an odds ratio could have been computed, it would have told us the probability of the number of dental hygienists who intende d to treat HIV/AIDS patients, versus the probability of the number of dental hygienis ts who intended not to treat HIV/AIDS patients. Research Question 6: Is there an association betw een dental hygienists knowing a friend or family member with HIV/AIDS, a nd intention to treat HIV/AIDS patients?

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134 A Mann-Whitney U test determined if th e nominal variable, knowing a friend or family member with HIV/AIDS, was associ ated with intention to treat HIV/AIDS patients. The non-parametric Mann-Whitney U test was used to compare the two groups, and is analogous to the parametric t -test. Table 4.15 found no statistically significant association between the mean ranks of the two groups ( p=.083). Table 4.15 Correlation of Intention Scale Scores with Knowing a Friend or Family Member with HIV/AIDS Do you have a friend or family member who has HIV/AIDS? N Mean Rank Sum of Ranks MannWhitney U Asymptotic Statistical Significance (2-tailed) INT Scale Score No 170 101.20 17203.50 2668.500 .083 Yes 38 119.28 4532.50 Total 208 Research Question 7: What is the measure of associ ation between dental hygienists intentions to treat, perceive d self-efficacy, perceived risk of being infected, and attitudes and normative beliefs about tr eating HIV/AIDS patients? In this study, two initial steps in regression diagnos tics were conducted to check for outliers and to determine that the chosen variables were normally distributed. Then, bivariate relationships were checked for linea rity, and scatterplots and histograms were used to visualize these relationships. The fi ndings led the researcher to change the type of regression analysis that was planned for research question 7. Initially, a multiple linear regression was planned to analyze the data. Ho wever, the bimodal, sk ewed distribution of the dependent variable changed that plan, and a binomial (bin ary) logistic regression was

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135 conducted instead. Based on the output from the univariate analyses of their intention score, two fairly evenly distributed groups of dental hygienists were formed with respect to their predicted action, in this case, dental hygienist s higher intention to treat or lesser intention to treat HIV/AIDS patients. Logistic regression determines which variables affect the probability of a particular outcome. Block 1 Based on results of bivariate analyses, five predictor variables were entered into the logistic regression using the Enter method to obtain the best fitting model for the data. The five predictor variables included Self-Effi cacy scale, Risk scale, Attitude scale, Normative Beliefs scale, and one variable from the practice context. For the six variables (one dependent and five inde pendents), 188 of 217 cases had valid values for this model ( N = 188). The model is summarized in Table 4.16. Omnibus tests revealed that this model was significant for all predictor variables ( 2 (5, N =188) = 71.781, p = .000). The statistically signi ficant Chi-square value meant that there was more chance of obtaining a signif icant model than if there was no effect of the independent variables on the dependent vari able. In other words, if the independent variables did not affect the dependent va riable, then nothing would be significant. How do we know if the data fit the model? Logistic regression applies maximum likelihood estimation to approximate the probabi lity of a certain event occurring. A good model results in a high likelihood of the observe d results, and means a small value of -2 Log likelihood (-2 LL). The log likelihood (LL) is its log and varies from 0 to minus infinity (it is negative because the log of a ny number less than 1 is negative). If the model fit perfectly, the -2 LL would equal 0. The -2 LL was 188.757. The

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136 nonsignificant Hosmer and Lemeshow goodness of fit test result (p = .714) indicated that the data fit the model. The classificati on table showed that 80% of the time, the independent variables correctly predicted in tention of dental h ygienists to treat HIV/AIDS patients, when all five of the i ndependent variables are in the model. The coefficient (standardized slope) repres ents the change in the logit of the dependent variable per unit change in the corresponding predictor variable. The Wald statistic tests the significance of the individua l logistic regression coefficients for each independent variable. Therefore, a significant value of the Wald statistic (p < .05 and p < .01) indicates that the coefficient for each independent va riable is significantly different from zero in the model. In this mode l, two predictors, Self-Efficacy scale ( = .145, p = .001), and Normative Beliefs scale ( = -.214, p = .003) made significant contributions toward predicting the outcome. The logistic regression identif ied Self-Efficacy scale as the strongest predictor of intention. The odds ratio in the model indicat es the change in odds per unit change in each predictor variable. An odds ratio of 1.157 indicated that for each point scored on the Self-Efficacy scale, dental hygienists were 1.157 times more likely to have intent to treat HIV/AIDS patients. As dental hygienists self-efficacy increased, the odds increased by 16% for participants being in the high intention group. The predictor variable, Normative Belie fs scale, was found to be the second strongest predictor of dental hyg ienists intention to treat HIV/AIDS patients. The odds ratio of .808 means that the odds of being in the high intention group decreased by 20% with each point added to the Normative Belie fs scale. In other words, the dental

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137 hygienists with higher norma tive scale scores are 20% le ss likely to be in the high intention group and to have intent to treat HIV/AIDS patients. Multicollinearity was assessed by review ing the correlation matrix. Correlation coefficients < .60 indicated that collinearity did not exist amo ng the predictor variables in the model. VIF values were well under 10 (a verage = 1.730), and to lerance values were well above .10 indicating there wa s no collinearity in the model. Table 4.16 Block 1: Logistic Regression Predicting Dental Hygienists Intentions to Treat HIV/AIDS Patients B S.E. Wald df Sig. Exp(B) SELF_Total .145 .043 11.430 1 .001 1.157 RISK_Total -.026 .083 .100 1 .751 .974 ATT_Total -.087 .069 1.615 1 .204 .916 NORM_Total -.214 .071 9.078 1 .003 .808 TRT_PTS_IN_ PRIV_PRAC .255 .464 .301 1 .583 1.290 Constant -2.282 2.242 1.037 1 .309 .102 a Variable(s) entered on step 1: SELF_Total, RISK_Total, ATT_Total, NORM_Total, TRT_PTS_IN_PRIV_PRAC. Block 2 The researcher examined the standardized residuals and deleted 4 cases that were considered to be outliers ( N = 184). A second logistic regression analysis was run, however, removing the cases did not change the signifi cance of the findings. Table 4.17 summarizes the logistic regression anal yses and includes the confidence intervals that identify the boundari es within which 95% of samples measuring the same variables as this study would fall (*p<.05)

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138Table 4.17 Summary of Logistic Regression Analyses Predicting Dental Hygienists Intentions to Treat HIV/AIDS Patients 95% C.I. for Exp(B) Variable Odds Ratio P value Lower Upper SELF_Total 1.157 .001* 1.063 1.258 RISK_Total .974 .751 .827 1.147 ATT_Total .916 .204 .801 1.049 NORM_Total .808 .003* .703 .928 TRT_PTS_IN_ PRIV_PRAC 1.290 .583 .520 3.200 Regression Summary The model was assessed by examining test results of the logistic regression analyses, statistical significance of predictor variables in the model, and results of the -2LL and Hosmer and Lemeshow goodness-of-fit tests. A binary logistic regression was the correct statistical test for this type of data because the dependent variable violated the assumption of normality. Using this model, it was not necessary to meet the stringent assumptions as is the case when running a multiple regression analysis. In summary, it is always important to choose the correct model for analysis, otherwise the results may be invalid, and any future studies may show different results.

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139 Chapter V Discussion, Conclusions and Recommendations Chapter V presents a discussion of the re search and conclusions drawn from the results obtained from the survey. This study ex amined beliefs, attitudes and intentions of dental hygienists in Florida who were members of the FDHA to investigate the relationships between a host of independent variables and dental hygienists intentions to treat HIV/AIDS patients. This study was based on the TRA, a decision model that incorporates the effects of personal and social factor s on behavior, and used a nonexperimental, cross sectional research design to analyze these relati onships. In addition, the study design permitted the examination of the strength and direction of the relationships among these variables that ma y serve as the basis for future studies, development of oral health education cu rricula for DHCPs, and policy development. This type of study is important, b ecause the epidemic is 26 years old, and recently, dental hygienists in 13 states sti ll reported feeling a ri sk of occupational transmission of HIV (King & Muzzin, 2005). Ot her studies cited in th e literature review revealed more than two decades of unchange d attitudes and practices associated with treating patients with infectious diseases. Unchanged attitudes and practices of DHCPs may stem from their fear of contracting a di sease that can alter or shorten life. Their perceptions may also contribute to the c linical practice choices made by clinicians.

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140 The researcher thought that similar findings would be able to be reported here, but the respondents did not express most of the same attitudes and practices that were described in previous studies dating back to the early 1980s. A discussion of the findings follows. Discussion of Results This section provides a summary of the results used to address each of the seven research questions in this study. Research Question 1: What are dental hygienists stated intentions, attitudes, perceived risk, perceived self-efficacy and normative be liefs toward treating HIV/AIDS patients? The mean scores of each of the seven in tention items (INT 1-7) indicated positive agreement of dental hygienists with respect to their willingness to treat HIV/AIDS, Hepatitis B, and Hepatitis C patients. The ten self-efficacy items (SELF 8-17) also had high mean scores that indicated belief in their clinical abilit ies to treat HIV/AIDS patients. While the use of standard (universal) precautions achieved the highest m ean score, all respondents stated that they used these mandated precautions in their workplace settings. The high scores indicated that the study participants were confident in their ability to treat HIV/AIDS patients. Four items (RISK 18-21) measured the risk of treating HIV+ patients. The low means of three items (RISK 18, 19, and 21) indi cated that dental hygienists did not worry about acquiring HIV from infected patients or from inadequate infection control practices in the workplace, nor did they worry about casual contact with people who are HIV+ or those who have AIDS. In contrast however, dental hygienists felt that they needed to know the HIV antibody status of their patient s (RISK 20), which may mean that they

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141 really do feel at risk when treati ng HIV/AIDS patients. The literature supports this finding among dental hygienists, especially the recent study by King & Muzzin (2005). The concurrence of findings means that it is more fact than myth. Because standard precautions have been mandated for infection control purposes, there is no reason to know this information. This finding cont radicts their unilateral response of using universal (standard) precautions in the workpl ace, which may be social response bias. Seven items (ATT 22-24, 27, 29, 30, 34) meas ured attitude toward treating HIV/AIDS patients, and showed that respondents thought they would not be putting themselves, patients, or others at risk if they treated HIV/AIDS pa tients. Their positive attitudes toward treating HIV/AIDS patients were consistent acros s all attitude items. Two normative belief items (NORM 25-26) revealed that the respondents did not allow the attitudes of others to affect th eir choice of clinically treating HIV/AIDS patients. When dental hygienists move fr om not allowing others to affect their decisions to allowing them to affect their de cisions, their intenti on to treat HIV/AIDS patients decreases. One item (NORM 28) measured the normative beliefs of dental hygienists perceptions of the expectations of their boss for them treating HIV/AIDS patients. The fact that dental hygienists agr eed with the statement: My boss thinks that I should provide dental hygiene care for any person who has HIV/AIDS, indicates that they perceive that their employers feel positively toward them treating HIV/AIDS patients, and is consistent with Flor ida BOD supervision requirements. Study participants disagreed that 1) dentists or dental hygienis ts who have HIV/AIDS should not be allowed to work in the dental field (NORM 31); 2) they should be allowed to refuse to provide care to persons with HI V/AIDS (NORM 32), and 3) their co-workers

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142 did not want to treat HIV/AIDS patients (NOR M 33). This meant that the direction of their response was positive, and overall, their normative beliefs did not hinder their intention to treat HIV/AIDS patients. Research Question 2: What is the association between dental hygienists intentions to treat and perceived self-efficac y, perceived risk of being in fected, attitudes and normative beliefs toward treati ng HIV/AIDS patients? Bivariate analysis of the dependent variable scale and th e four independent variable scales was conducte d. Results showed that all four scales were strongly correlated with the de pendent variable (p < .001). This set of correlations means that: 1. respondents who reported that they we re capable of treating HIV/AIDS patients in a clinical setting, also had positive intentions to do so; 2. as their perception of the risk of occupational transmission decreased, dental hygienists intention to tr eat HIV/AIDS patients increased; 3. as participantsnegative attitudes and normative beliefs decreased, their intentions toward treating HIV/AIDS patients increased. Bivariate analysis also was conducted for the intention scale and the eleven demographic variables. Only one statistica lly significant associ ation was found between the INT scale and having treate d patients in private practi ce (see Research Question 5). The remaining ten demographic variables s howed no measure of association with the dependent variable. This result means that dental hygienists who ha ve clinically treated HIV/AIDS patients in private practice have a positive intention to do so. Research Question 3: Is there an association between y ears in practice, and intention to treat HIV/AIDS patients?

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143 The results of a Spearman rank-order corr elation test showed that there was no statistically significant associ ation between the number of years in practice, and the participants intention to treat HIV/AIDS patients. In fact, the Spearman rank-order correlation value suggested that the more years that dental hygienists practiced, there was slightly less intention to treat HIV/AIDS patients. Research Question 4: Is there an association between ev er treated an HIV+ patient as a student, and intention to treat HIV/AIDS patients? A Kruskal-Wallis H test was conducted to investigate whether a dental hygienist who had treated an HIV+ patient as a student ha s an intention to treat HIV/AIDS patients. The test results were not significant at this level of analysis, and meant that there was no significant difference among the th ree groups of study participan ts (yes, no, dont know). Although a significant difference did not exist among the three groups, the researcher recoded the data into two groups (yes, no (no + dont know)). Further analysis using a Mann-Whitney U test revealed th at there still was no significant difference between the groups. This result means that the respondents did not ba se their decision to treat HIV/AIDS patients on whether they had or had not treated pe rsons with HIV/AIDS as students. Research Question 5: Is there an association between ev er treated an HIV+ patient in private practice, and intention to treat HIV/AI DS patients? Similar to research question 4, a Kruskal-Wallis H test was conducted to investigate whether a dental hyg ienist who had treated an HIV+ patient in private practice may has an intention to treat HIV/AIDS patie nts. This association was statistically significant, and further analyses of three pairwise comparisons using a Mann Whitney U

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144 test revealed one signi ficant association. After transfor mation to a nominal variable was completed, results showed that there was a significant difference between those who have, and those who have not treated patients in private practice, and their intention to treat HIV/AIDS patients ( p<0.000). This result meant that dental hygienists who had treated HIV/AIDS patients in private practi ce had greater intenti on to do so, whereas those respondents who had not treated HIV/AI DS patients in private practice had a lesser intention to do so. Research Question 6: Is there an association betw een knowing a friend or family member with HIV/AIDS, and intent ion to treat HIV/ AIDS patients? A Mann-Whitney U test was conducted to evaluate whether knowing a friend or family member with HIV/AIDS was related to their intention to treat HIV/AIDS patients. The results were not statistically significant. The lack of association between the two variables means that the respondents inten tions to treat HIV/AI DS patients did not depend on knowing a friend or family member with HIV/AIDS. Research Question 7: What is the measure of associ ation between dental hygienists intentions to treat, perceive d self-efficacy, perceived risk of being infected, and attitudes and normative beliefs about tr eating HIV/AIDS patients? A logistic regression was conducted with six variables (one dependent, and five independent) that were chosen as a result of previous univariate and bivariate analyses. The first model (Block 1) found that the Self -Efficacy and Normative Belief scales were significantly associated with the Intention scal e. This association meant that as dental hygienists self-efficacy increased, the odds fo r them being in the high intention group increased also. However, dental hygienists who had higher normative belief scale scores

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145 were less likely to be in the high intenti on group, because they allowed other peoples beliefs to influence their behavior. Next, f our outliers were excluded from the analysis, and a second model (Block 2) was compute d. This second model did not change the significance of the findings. Recommendations The researcher has identified three re commendations as a result of this study. Recommendation 1: Mandate Florida Board of Dentistry CE requirements every two years for dentists and dental hygien ists in the area of HIV/AIDS. Eighty percent (80.2%) of the respondents in this study reported they had treated HIV/AIDS patients in private practice. This large proportion did not include the 16% of practitioners who reported that they did not know if they had treated HIV+ patients. Because the majority of dental hygienists in this study reported having treated this population, and because the nature of the dis ease and treatment options keep changing, there is a need to continue to mandate cont inuing education require ments in Florida. Another imperative reason to continue this process is that Florida has one of the largest HIV/AIDS populations in the nation. Re-licensure of dental prof essionals in Florida occurs every two years. Prior to 2006, dentists and dental hygienists were re quired to attend at least one hour of HIV/AIDS update training ever y other year. The 2006 legi slation only mandates it once for dentists/dental hygienists before they re new their license for the first time. In 2003, the CDC recommended: Personnel subject to occupational exposure should receive infection control training when they begin th eir job, when new tasks or procedures affect their occupational exposure, and at the least, on an annual basis (( MMWR report (52, RR-

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146 17; CDC, 2003). Based on findi ngs in this study, 63% of dent al hygienists felt that they needed to know the HIV antibody status of their patients, which contradicted their unilateral response (100%) of using universal (standard) precautions in the workplace, and may mean that they really do feel at risk when treating HIV/AIDS patients. Because standard precautions have been mandated for infection control purposes, there is no reason to know this information. Based on the 2005 study of dental hygienists in 13 states the dearth of knowledge exhibited about HIV transmission confirme d the need for continuing education on infectious disease and modes of transmi ssion. This study did not obtain information about respondents knowledge of HIV transmission. Recommendation 2: Incorporate cultural/sensiti vity training in all dental/dental hygiene school curriculums. HIV/AIDS is not just a medical issue. From a policy perspective, it is also a political and social issue. The stigma and discrimination surr ounding HIV/AIDS has made it different from how people view other sexually transmitted di seases, tuberculosis, or even cancer. When it was first repo rted in 1981, the resu rgence of right wing fundamentalist principles of personal respons ibility, sin, and sexual deviation had made a comeback among the American populace and was tacitly supported or at least condoned by government administrations. The sexual, cult ural and social factors of the 1980s made the treatment of this disease different than if it had manifested itself in the 1940s, 1950s, or 1960s when it most probably would have been treated differently. But the fact that HIV/AIDS was first discovered in the gay population exacerbated a conservative and moralistic movement that disenfranchised groups such as homosexuals and lesbians

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147 because of the link to sexual transmission ove r other forms of disease transmission. One outcome of this thinking has been the funding of abstinence-only sex education, and refusal at some official policy levels to acknowledge other avenues of disease prevention. The polar opposite of that was the extr eme left wing that adopted political and social correctness as its agenda. The indi vidualistic agenda allowed people to become more litigious and to think of themselves as victims. The social creed of the left wing was the idea of victimology which meant that people were not responsible for their actions, and that they were victims of the system. Political and social forces were working against each other, and affected government policy and funding of HIV/AIDS. It also affected how American society viewed this disease with stigma and discrimination. A UCLA study on HIV stigma revealed that one in four people living with HIV felt stigmatized by their health care pr ovider (Kinsler, Wong, Sayles, Davis, & Cunningham, 2007). Kinsler, et al, (2007) showed that a pproximately one-fourth of respondents reported perceived stigma at ba seline, and one-fifth reported these same findings at follow-up. These findings are of pa rticular importance, because lack of access or delayed access to care may result in patient s presenting with more advanced stages of disease, and the likelihood of earlier mortality. Therefore, interventions are needed to reduce perceived stigma in th e health care setting. E ducational programs and roleplaying (modeling) of non-stigmatizing behavior can teach health care providers to provide unbiased care. In addition, a tool kit was developed to raise awareness and promote action to challenge and reduce HIV stigma among different target groups that included health care professionals: Understanding and Challenging HIV Stigma: Toolkit

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148 for Action (2003; http://www.changeproject.org/). The first three objectives of the toolkit are specific to health care providers and incl ude: 1) build ownership of the problem and help everyone see that HIV stigma exists and really hurts, and that we can be a part of reducing stigma; 2) deepen understanding on HI V/AIDS to help people deal with their fears in the workplace, and misconceptions about what happens when someone becomes infected, and 3) provide a safe place for people to discuss their fears, values and attitudes towards persons living with HIV and/or AIDS (PLHA) and take ownership of a new set of values. Even with the growth of a global philosophy, many Americans including health care providers lack cu lturally appropriate skills. Although sensitivity training around HIV is available to health care wo rkers, currently there is no universal requirement for medical or dental pr ofessionals to undergo such training. Recommendation 3: Increase access to oral health care for persons with HIV/AIDS by legislating to eliminate barriers to practice. On July 20, 2006, Pennsylvania Governor Ed Rendell signed into law the first of a series of bills in his comprehensive plan to provide greater access to high quality care to all Pennsylvanians at affordable costs. The building block in the Governors health reform plan was to utilize the professional he alth care workforce in the state more fully. The bills signed into law expanded access to health care providers by eliminating barriers to practice to the fullest extent permitted by the providers scope of practice, and by expanding the scope of practice in certain cases This legislation is important because it represents the first state to make explicit workforce changes as a solution to improving access at affordable costs. The general rule states that it allows Certified Registered Nurse Practitioners, Clinical Nurse Specialis ts, Physician Assistants, Nurse Midwives,

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149 and Independent Dental Hygienist Practitione rs to take medical histories, perform physical or mental examinations, and to provi de acute illness or minor injury care or management of chronic illness in the same manner as physicians and dentists, as long as those activities fall within their specialty certification and scope of practice. The Independent Dental Hygienist Practitioner is established as an identified provider who can perform the functions of a dental hygienis t at specified sites w ithout the supervision of a dentist. This enactment in Pennsylvani a makes 22 states that currently have less restrictive practi ce options for dental hygienists. Kansas allows dental hygienists who have a passion for taking care of the unders erved to obtain an Extended Care Permit (ECP) to take care of persons who have no access to a dentist or any type of dental care (F. Catalanotto, personal communication, July 29, 2007). In 2007, the South Carolina Board of Den tistry (SCBOD) settled charges that it restrained competition in the provision of preventive care by dental hygienists. The Federal Trade Commission (FTC) alleged that this conduct limited needy childrens access to care (Appendix G). The FTC announced on June 27, 2007 that a consent order had settled charges brought in September 2003 that the SCBOD unlawfully restrained competition in violation of Sec tion 5 of the FTC Act when it a dopted a rule that required a dentist to examine every child before a de ntal hygienist could pr ovide preventive care in schools. The problem was that the SCBOD adopted the rule in 2001 after the South Carolina legislature had eliminated a statutory requirement that a dentist was required to examine each child before a dental hygienist could perform the preventive dental care in schools. The FTC alleged that the SCBO Ds anticompetitive conduct led to fewer children, especially the economically disadvantaged, receiving preventive dental services

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150 in schools. This case set a new precedent and told state regulatory boards that if they restricted competition in ways not contemplat ed by state law, they would be subject to the antitrust laws of the FTCs Bureau of Competition (Byrd, T., 2007, June 26). On February 19, 2008, Floridas Governor Ch arlie Crist, released his top three priorities of the 2008 Legislative Session: 1) health care; 2) edu cation, and 3) energy and economic development. Within the area of heal th care, Governor Cris t specifically noted access to dental care, and has included the following points in proposed legislation: Enhance the recruitment of dentists to work in public health settings; Maximize the services hygienists may provide in public health settings; similar to the FTCs charges ag ainst the SCBOD noted above; Require that two of seven Board of De ntistry member dentists have public health experience; Permit Medicaid to pay doctors and nurses to provide fluoride varnish services for children birth to age three during Well Child visits; Expand community dental services in rural areas for persons with disabilities, and Increase Medicaid reimbursement to dentists by 20%. The Florida BOD intends to challenge the Governors legislation. Two bills were introduced by the FDHA during the opening of the 2008 Florida le gislative session to challenge the Florida dentis ts position of disallowing a change in supervisory requirements for dental hygienists that coul d ultimately make a difference in improving access to care for patients. In addition, the FDHA is fighting the Florida BOD on its decision to allow dental assist ants to perform some clinical duties of dental hygienists

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151 that puts Floridians at risk for possible patient safety violations, because there are no mandatory education requirements for dental as sistants as they may be trained on-the-job. Currently, Oklahoma dental hygienists are fighti ng a battle to allow dental assistants to perform dental hygienists duties in a preceptorship (on-the-job) mode. Strengths of the Study The study is substantive. The study has added to th e body of dental and public health literature. The topic of HIV/AIDS and intention to treat HIV+ patients within dental workplace settings has not been resear ched in the state of Florida, and only has been marginally researched nationally and inte rnationally. This study showed that dental hygienists who are members of the FDHA have an intention to treat HIV/AIDS patients. The next step would be to survey the entire population of Florida dent al hygienists on this and other topics related to HIV/AIDS. This study validates methodologies used. The survey instrument was validated through several methods: 1) face validity and content validity proce sses; 2) live pilot session of using the instrument; 3) pilot session testing instrument reliability; 4) email survey validated by data received from USF IT Dept. The study is relevant. Access to dental care for low income, underserved, and unserved populations continues to be a major concern to pub lic health professionals in Florida. This study focuses on dental hygi enists and their inte ntion to treat the HIV/AIDS population in Florida. The HI V/AIDS population has had little access to dental care due to the dearth of dental profe ssionals who have been w illing to treat them. While 80% of respondents repo rted treating HIV/AIDS patie nts, it was assumed that either these patients had dental insurance, and / or they were able to pay for services. A

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152 large number of newly diagnosed individua ls with HIV/AIDS are young minority women who have little access to de ntal care, because they ar e on Medicaid or cannot pay themselves. Governor Crists statistics show that 52% of Florida c ounties currently have one Medicaid dentist, while the remaining c ounties have none, and thereby supports the issue of lack of access to dental care in Florid a for specific populations such as those with HIV/AIDS. The study is timely. As a result of Florida Governor Crists legislative priorities, dental public health will be expanded to treat low income and persons in poverty. The outcome of legislating these priorities will increase access to and av ailability of dental health services. Reducing the impact of the Florida BOD rulings will allow DHCPs to work in an expanded public health sector a nd provide services to the populations that really need them, and that are mostly not made available by priv ate sector providers. Weaknesses of the Study Small sample; Inability to generalize findings. Although a 22% response rate was achieved, the actual numbe r of useable surveys (217) wa s small even though the total number of FDHA members were contacted a nd asked to participate. Whereas the response rate was adequate to answer the research questions posed, participation was contingent on dental hygieni sts receiving and reviewing the email and mailed postcard messages, and having a computer and sufficien t knowledge of the Inte rnet to access and respond to the survey. The researcher origin ally wanted to survey all Florida dental hygienists. Because it was not possible to obta in email addresses from the state BOD, the FDHA was willing to provide them to the researcher. Dental hygienists who are members of FDHA may differ from non-member dental hygienists in Florida in terms of

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153 their beliefs, attitudes, intent ions and clinical practices. Therefore, the results of this study cannot be generalized to non-FDHA memb ers, or to other dental hygienists nationally or internationally. Email addresses on file and data collection lessons learned. Whereas approximately 60% of respondents had an email address on file with FDHA, 115 members were found to have non-useable ema il addresses, therefor e, approximately 500 members received the survey information via email. The remainder of respondents received postcards in the mail that informed them of the web address to link them with the survey. No postcards were returned st ating they could not be delivered, so it was assumed that they reached the intended recipients. The first lesson learned was to be aware that people change email addresses, and use spam blockers. The researcher must over sample to account for this difference, how ever, it was impossible to over sample in this study, because the entire FDHA membership was surveyed. On July 17, 2007, after the first mailing, it wa s determined that the survey link on the postcard was missing one letter. Post cards were reprinted and were re-mailed immediately, announcing the error. The lesson he re is to always check the accuracy of the link prior to printing, because the re-m ailing may be confusing to respondents, and the added expense may be unnecessary. Implications for Public Health This study adds to both public health and de ntal health literature in the areas of access to care, infectious disease, willingness to treat, normative beli efs, attitudes, selfefficacy, and perceived risk of disease transmission.

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154 Although HIV/AIDS has become known as a chronic disease, it is still recognized first as an acute infectio us disease (Scandlyn, 2000). With the large number of HIV/AIDS cases in Florida, knowing how to treat this population is imperative. In addition to clinical training, public health education and cu ltural sensitivity training may help to increase knowledge and to reduce st igma among dental health care providers. Changing this perception is paramount to reducing the fear about HIV/AIDS that has not been eliminated to date. The provision of trai ning of health professi onals in cultural and sensitivity issues will allow DHCPs to serve patients more effectively by eliminating this barrier. The World Health Organization (WHO ) has recognized the impact of HIV/AIDS worldwide and declared December 1st as annual World AIDS Day to promote awareness, encourage discussion, and mobilize action in th e quest toward achieving parity among the HIV-infected and non-infected populations. Results from this study provide additional evidence for decreasing supervision requirements of dental hygienists in Flor ida, thereby increasi ng access to dental care services for the underserved populations such as the HIV-infected, the elderly, school-age children, the mentally challenged and th e disabled. Reducing the supervisory requirements would allow dental hygienists to provide the same care they currently provide in dental offices in public health settings, which may improve the health care status of these populations overa ll. This expansion of servic e venues may directly relate to reduced mortality and mo rbidity among these populations. Implications for Future Research The results of this study implore investig ating both licensed dentists and dental hygienists in Florida to compare group differences, and then to evaluate the differences

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155 between those who do belong or do not belong to their professi onal associations. Because of the subservient relationship of dent al hygienists to dentis ts in Florida who are governed by the Board of Dentistry, group diffe rences would be especially important to note at this point in time. Analyzing the group data by membership status in professional organizations would further substantiate this study, and the development of oral health education curricula for DHCPs. Examining the strength and direction of the relationships among these variables could serve as the basis for later studies. For example, the difference between ADHA (American Dental Hygienists Association) members and non-members was reported in a study by King and Muzzin (2005) who found that membership in a professional organization may have impacted the attitudes and practices of s ubjects through exposure to cu rrent research in disease transmission. ADHA members were less likely to alter practices when treating infectious disease patients. The findings suggest that having greater access to research publications and continuing education programs through loca l, state and national associations may make members more knowledgeable about in fectious disease transmission, thus decreasing the likelihood of f eeling a need to alter clinical practices. Therefore, education is vital in effecting change in the attitude s and practices of dental hygienists when treating patients with in fectious or unknown diseas es. Better education links directly with the first two recommendations. Future research comparing pre-and-post access to dental care for low income, underserved, and unserved populations in Florida is warranted should Governor Crists legislation be passed. Results may show a significant change in access to health care, especially dental health car e, for these currently unrecogni zed populations. In addition,

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156 research into the change in health status of these different populations would be reasonable. Afterthoughts In the mid-1990s and ten years after the fi rst CDC infectious disease guidelines were written, Silverman (1996) wrote: There is no end in sight for the HIV/AIDS pandemic. Therefore, with or without knowledge of their own serologic status, HIV-infected patients will be seeking dental care in increasing numbers in the decade ahead. Additionally, the diagnosis and management of frequently occurring HIV-associated oral lesions will add to dental responsibilities. By following infectious disease guidelines for blood-borne pathogens, dental clinicians, office workers an d patients will have an extremely low risk for HIV transmission (p.53). Dental professionals, either knowingl y or unknowingly, will be treating HIV+ patients for years to come, and the general pr actitioner will likely continue to carry the main burden (Silverman, 1996). Beliefs and at titudes held by clinicians as well as patients are the basis for con cern regarding HIV transmission risks and office procedures. The differences in attitude among clinicians and office staff have cr eated stresses that have dictated office culture, atmosphere a nd functions. The sensitivity of patients and staff members has been an important issue in office functions. Critical considerations influencing judgments have been based on th e deadliness of the HIV virus, emotional attitudes and misconceptions, le gal and political implications, family pressures, economic factors, understanding, knowledge and compa ssion. More than anything now, we must

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157 put down these judgments and face the future with optimism and strength that paves the way toward improved oral health stat us for those who are HIV-infected. Personals During data collection, I received an ema il from a dental hygienist who was soon relocating back to Haiti: I am impressed that you are conducting this research and using this survey to assist with treatment for those that need it, no matter what thei r health status; as they need it the most! I remember when this disease was first "discovered and named" and the 'stigma' that followed. I have compassion for all-those infected and those in our profession that choose not to treat. May there be more of us that do choose to provide dental hygiene se rvices. Good luck on furthering your education and assisting those that ne ed our services (K. Barton, personal communication, July 12, 2007; see Appendix I).

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158 List of References Aday, L. A., & Forthofer, R. N. (1992). A profile of Black and Hispanic subgroups' access to dental care: Findings from the National Health Interview Survey. Journal of Public Health Dentistry, 52 210-215. AIDS Alliance For Children Youth & Families. (2003). Living with an HIV diagnosis Retrieved August 10, 2005, from http://www.aidsalliance.org/aids_alliance/index.html Ajzen, I. (Ed.). (1985a). Action control: From cognition to behavior. New York: Springer-Verlag. Ajzen, I. (Ed.). (1985b). From intentions to actions: A theory of planned behavior New York: Springer-Verlag. Ajzen, I., & Fishbein, M. (1980). Understanding attitudes and predicting social behavior. Englewood Cliffs, NJ: Prentice Hall. American Medical Association. (1871). Code of ethics adopted May 1847 Philadelphia, PA: American Medical Association. American Public Health Association. (2004 April). Priorities outlin ed to counter global oral disease problems. The Nation's Health, p. 18. Angelillo, I. F., Nardi, G., Rizzo, C. F., & Vi ggiani, N. M. (2001). Dental hygienists and infection control: knowledge, a ttitudes and behavior in Italy. Journal of Hospital Infection, 47 (4), 314-320.

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159 Angelillo, I. F., Villari, P., D'Errico, M. M., Grasso, G. M., Ricciardi, G., & Pavia, M. (1994). Dentists and AIDS: a survey of knowledge, attitudes, and behavior in Italy. Journal of Public Health Dentistry, 54 (3), 145-152. Associated Press. (2003, November 14) ACLU: AIDS discrimination persists St. Pete Times, p. 8A. Baker, S. A. (1988). An application of the Fishbein Model for predic ting behavioral intentions to use condoms in a sexually transmitted disease clinic population. Unpublished Dissertation, University of Washington. Baldo, V., Floreani, A., Dal Vecchio, L., Cristofo letti, M., Carletti, M., Majori, S., et al. (2002). Occupational risk of blood-borne viru ses in healthcare workers: a 5-year surveillance program. Infection Control in Hospital Epidemiology, 23 (6), 712. Barr, S. (1994a, April). In de fense of the AIDS dentist. Lear's Magazine, 68-82. Barr, S. (1994b, April 16). What if the dentist didn't do it? The New York Times, p. op ed page. Barr, S. (1996). The 1990 Florida dental i nvestigation. Is the case really closed? Annals of Internal Medicine, 124 (2), 250-254. Beetstra, S., Derksen, D., Ro, M., Powell, W., Fry, D. E., & Kaufman, A. (2002). A "health commons" approach to oral health for low-income populations in a rural state. American Journal of Public Health, 92 12-13. Blumenfield, M., Smith, P. J., Milazzo, J., Seropian, S., & Wormser, G. P. (1987). Survey of attitudes of nurses working with AIDS patients. General Hospital Psychiatry, 9 58-63.

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160 Breault, A. J., & Prolifroni, E. C. (1992). Ca ring for people with AIDS: Nurses' attitudes and feelings. Journal of Advanced Nursing, 17 21-27. Brown, D. (1996). The 1990 Florida dental investigation. Theory and fact. Annals of Internal Medicine, 124 (2), 255-257. Burris, S. (1994). Law and ethics and the decision to treat. In M. Glick (Ed.), Dental management of patients with HIV (pp. 25-40). Carol Streams, IL: Quintessence Publishing Co., Inc. Burris, S. (1996). Dental discrimination agai nst the HIV-infected: Empirical data, law and public policy. Yale Journal of Regulation, 13 (1), 1-104. Byrd, T. (2007, June 26). South Carolina Bo ard of Dentistry sett les charges that it restrained competition in the provision of preventive care by dental hygienists: FTC complaint alleged conduct limited needy children's access to care. [Msg 2]. Message posted to dental -public-health@list.pitt.edu. Cai, G., Moji, K., Honda, S., Wu, X, & Zha ng, K. (2007). Inequality and unwillingness to care for people living with HIV/AIDS: a survey of medical professionals in Southeast China. AIDS Patient Care & STDs, 21 (8): 593-601. Catalanotto, F., & Delinger, J. E. (2007). These persistent dental hygienists are at it again. Retrieved July 29, 2007 from http://www.dental-publichealth@list.pitt.edu. Centers for Disease Cont rol. (1981a, August 28). Follow up on Kaposi's sarcoma and pneumocystis pneumonia from http://www.cdc.gov/hiv/pubs/mmwr/mmwr28aug81.pdf

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161 Centers for Disease Control. (1981b, July 4). Kaposi's sarcoma and pneumocystis pneumonia among homosexual men New York City and California. Retrieved 8/3/06, from http://www.cdc.gov/hiv/ pubs/mmwr/mmwr04jul81.pdf Centers for Disease Cont rol. (1981c, June 5). Pneumocystis pneumonia Los Angeles from http://www.cdc.gov/hiv/pubs/mmwr/mmwr05jun81.pdf Centers for Disease Control. (1985). Recommendations for preventing transmission of infection with human T-Lymphotropic viru s type III/ lympha denopathy-associated virus in the workplace Centers for Disease Control. (1986). Recommended infection-control practices for dentistry Centers for Disease Control. (1987). Recommendations for prevention of HIV transmission in health-care settings Centers for Disease Control. (1988). Perspectives in disease prevention and health promotion update: Universal precauti ons for prevention of transmission of Human Immunodeficiency Virus, hepatitis B virus, and other bloodborne pathogens in health-care settings Centers for Disease Control. (1989). Guidelines for prevention of transmission of human immunodeficiency virus and hepatitis B virus to health-car e and public-safety workers. Centers for Disease Control. (1991a). Recommendations for preventing transmission of human immunodeficiency virus and hepati tis B virus during exposure-prone invasive procedures

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181 UNAIDS. (2004a, July 9). Fact sheet: Women and AIDS A growing challenge Retrieved July 9, 2004, from http://www.unaids.org/html/pub/publications/factsheets04/FS_Women_en_pdf/FS_Women UNAIDS. (2004b, November 2). HIV/AIDS survey indicators database. Retrieved November 2, 2004, from http://www.measuredhs.com/hivdata/prog_detl.cfm?prog_area_id=3 UNAIDS/WHO. (2003, December). Defusing stigma and discrimination. Retrieved January 24, 2005, from http://www.unfpa.org/hiv/docs/unai ds_epidem ic_update_2003-english.pdf United States General Accounting Office. (1992). AIDS: CDC's investigation of HIV transmission by a dentist : GAO/PEMD publication no. 92-31. van Servellen, G., Sarna, L., Padilla, G., & Brecht, M. L. (1996). Emotional distress in men with life-threatening illness. International Journal of Nursing Studies, 33 551-565. Vazquez, L., & Swan, J. H. (2003). Access a nd attitudes toward oral health care among Hispanics in Wichita, Kansas. The Journal of Dental Hygiene, 77 (II). Venes, D., Thomas, C. L., & Taber, C. W. (2001). Taber's cyclopedic medical dictionary (19th ed.). Philadelphia: F. A. Davis Co. Verrusio, C. A., Neidle, E. A., Nash, K. D ., Silverman, S., Horowitz, A. M., & Wagner, K. S. (1989). The dentist and infectious diseases: a national survey of attitudes and behavior. Journal of the American Dental Association, 118 553-562. Waldman, H. B. (1992). An increasing Hispanic population and the practice of dentistry. Illinois Dental Journal, 61 81-85.

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182 Wambach, K. (1997). Breastfeeding intentions and outcome: A test of the theory of planned behavior. Research in Nursing and Health, 20 51-59. Weitz, R. (1989). Uncertainty and th e lives of persons with AIDS. Journal of Health and Social Behavior, 30 270-281. Wertz, D. C., Sorenson, J. R., Liebling, L., Ke ssler, L. & Heeren, T. C. (1988). Caring for persons with AIDS: Knowledge and attitudes of 1,047 health care workers attending AIDS Action Committee education programs. Journal of Primary Prevention 8 (3), 109-124. West Central Florida Ryan White Care Council. (2004). Ryan White Title I direct client service expenditures, oral health expenditures Whetton-Goldstein, K., & Nguyen, T. Q. (2002). You're the first one I've told: New faces of HIV in the South. New Brunswick, NJ: Rutgers University Press. Wilson, N. H., Burke, F. J., & Cheung, S. W. (1995). Factors associ ated with dentists' willingness to treat high-risk patients. British Dental Journal, 178 (4), 145-148. Zabos, G. P., Northridge, M. E., Ro, M. J., Trinh, C., Vaughan, R., Howard, J. M., et al. (2002). Lack of oral health care for adults in Harlem: A hidden crisis. American Journal of Public Health, 92 (1), 49-52.

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183 Appendix A: Permissions

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184

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Appendix A (Continued) 185 Appendix B Permissions

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Appendix A (Continued) 186

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Appendix A (Continued) 187From: Deborah Preston [dqp@psu.edu] Sent: Friday, September 30, 2005 5:21 PM To: Clark-Alexander, Barbara Subject: RE: NAAS Scale You're most welcome!!! deb At 02: 10 PM 9/30/2005, you wrote: Thank you so much Dr. Preston, for allowing me to adapt your NAAS instrument, and I am very impressed with your new stigma instrument as well. I have the first two articles which you listed, and will get the third one. Thanks again for your help and for your kind words. Barbara Clark-Alexander -----Original Message----From: Deborah Preston [mailto:dgp@psu.edu ] Sent: Friday, September 30,2005 12:24 PM To: Clark-Alexander, Barbara Subject: Re: NMS Scale Dear Barbara I am sorry for the delay in responding to your request I have been out of the country. But thank you for your interest in the NAAS. I would think that it could be adapted to dental hygienists. You have my permission to use and adapt the NAAS to your needs. I have not used it for awhile because I have been developing measures of stigma related to IllV and homosexuality. So I am attaching both just in case you might find our current work useful as well. I can also refer you to three articles we have written that might be useful: Preston, DB, Young, E.W. et al (1995) Th e Nurses' Attitudes about AIDS Scale: Development and Psychometric Analysis. AIDS Education and Prevention 7(5) 443-454. Preston, DB et al (2000) Personal and Social Determinants of Rural Nurses' Willingness to care for Persons with AIDS. Research in Nursing and Health, 23, 6778. Preston DB, D'Augelli AR, Kassab CD, Cain RE, Schulze FW, Starks MT. (2004) The influence of stigma on the sexual risk behavior of rural men who have sex with men. AIDS Education and Prevention, 16(4):291-303.

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Appendix A (Continued) 188 All the best in your doctoral work and let me know if there is anything else I can do. Sincerely Deb Preston At 11:14 AM 8/12/2005, you wrote: Dr. Preston, I am a graduate student at the University of South Florida, Tampa, FL, and am currently writing my dissertation. My dissertation topic is looking at attitudes, intentions and behaviors of dental hygienists in treating HIV/AIDS patients. I am in process of trying to find an instrument that would be acceptable for my study. I am interested in the NAAS (Nurses' Attitudes about AIDS Scale) the you were involved in developing and analyzing. Would you be willing to share the NAAS with me? Or would you be able to point me in the right direction toward an instrument that I could use? I am having difficulty locating one. Thank you for your time Dr. Preston, and I look forward to hearing from you. Barbara Clark-Alexander, RDH, BS, MPH, Doctoral Candidate Deborah Bray Preston 3296 Shellers Bend, # 144 State College, P A 16801 814-861-4332 dqp@psu.edu http://www .personal. psu. edu/ dqp/ ************************************************************************** The HSC AntiVirus Server has scanned this email and attachment{s) for email was found not to be infected. As always, please insure that th software on your local machine is kept up to date. ********************************************************************* Deborah Bray Preston, PhD Professor Emerita of Nursing Penn State School of Nursing 205E Health and Human Development East University Park, P A 16802 814-861-4332 dqp@psu.edu http://www.personal. psu. edu/ dqp/

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Appendix A (Continued) 189 From: Katherine Woods [Woods.Katherine@spcollege.edu] Sent: Friday, October 21, 2005 11 :00 PM To: Tami Grzesikowski; Clark-Alexander, Barbara Cc: LindaK Johnson; Christine Patel; Marta De La Torre; Maryellen Tilly Subject: RE: My Dissertation How about if we have the sophomores do this on a Friday during lunch time (if they want to)? Katie From: Tami Grzesikowski sent: Fri 10/21/20052:14 PM To: Clark-Alexander, Barbara Cc: LindaK Johnson; Katherine Woods; Christine Patel; Marta De La Torre; Maryellen Tilly Subject: RE: My Dissertation I certainly don't mind but I don't teach them in the classroom. If I can find a willing faculty to assist you by distributing it we would gladly help out. I will copy them and let you know. Congratulations on your accomplishments thus far, Tam; TamiGrzesikows,RDH MEd Dean, School of Dental Hygiene st. Petersburg College From: Clark-Alexander, Barbara [mailto:bclark@hsc.usf.edu] sent: Friday, October 21, 2005 1:16 PM To: Tami Grzesikowski Subject: My Dissertation Importance: High Tami, I have been working on writing my dissertation and assembling my questionnaire to survey members of the FDHA who have email addresses about their attitudes and intentions to treat HIV/AIDS patients. May I pilot the questionnaire using your dental hygiene students (not the bachelor degree students since they may be members of FDHA)? How many students are in your 2year program? I will be ready to do this in approximately 2 weeks. We can arrange the logistics if you consent to this. Please let me know, and thanks in advance for your time. Barbara Clark-Alexander

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Appendix A (Continued) 190 From: Tami Miller [tami@fdha.org] Sent: Tuesday, November 14,200611:05 AM To: Clark-Alexander, Barbara Subject: Re: Dissertation Plan B From Tami Miller, FDHA Hi Barbara, It nice to finally meet you as well. I can provide member labels, but cannot filter out those with emails. Can you share the survey with me and w hat kind of questions that you will be asking?? If so, I might be able to waive the fee for the labels. Tarni Clark-Alexander, Barbara wrote: > Hi Tami, > I was great to finally meet you at the dental hygiene conference. > You did such a super job planning it! Although I was there only one > day, I really learned a lot from the 3 sessions that I attended. I > thought it was super cool that your Morn was there helping. It is nice > to still have a Morn. > I presented my proposal to my doctoral committee on Oct. 20th. > The backup plan was suggested and developed because there are not > enough potential subjects with email addresses to give me significant > results, if any should be realized. A larger sample is necessary. > Therefore, the backup plan includes sending postcards with my URL to > members who do not have an email address. Th is method is better than > mailing surveys to them multiple times, because it allows all t he data > to corne into our IT/IS Dept., reduces potential error with data entry > (if mailed surveys were used), and is much less costly and intrusive. > My plan is to run the e-mailings, and postal mailings simultaneously. > A total of 4 postal mailings will occur at the same time as when I email the group with ema il addresses. I would like to know if you would consider giving me mailing labels for the hygienists who do not have email addresses? I will pay for the labels, as I need 4 sets The goal is to get the postcards printed in Nov. and afix labels and stamps in Dec., as my adv isor has set Jan. 15th as the target date to begin my survey. > You asked me to write a brief introduction > do that. It will be emailed ar ound Jan. 12th. call me (813-974-6641-work; 813-334-5305-cell) > questions. Thank you Tami. > Barbara Clark-Alexander > P.S. I am working with Debbie Heysek at Hillsborough Community College where I conducted Phase 2 of the pilot study. Katie Woods from St. Pete College is letting me work with her 2nd year students to check reliabilit y. I am scheduling that now.

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Appendix A (Continued) 191 From: Sent: To: Subject: Tami Miller [tami@fdha.org] Thursday, May 24, 2007 8:24 AM Clark-Alexander, Barbara Re: Quick Response Requested from FDHA Hi Barbara, I will mail to you today: 4 mailing label sets of members with no emails and a hard copy of members with emails. I've also attached this list to this email. There are 613 members with emails (371 without). I need the words that you want on the email blast from ADHA at your earliest convenience. Make it from you as a member requesting assistance from other members. Tami Clark-Alexander, Barbara wrote: Tami, This is perfect for the email blast. Could you check on the status of the mailing labels, and permission for me to make 3 more sets? The postcards are mailed four times as reminders to those without email addresses to log into the survey. The clock begins running with the ADHA blast, and will continue for one month so I will need them soon. Thank you so much Tami! Barbara > > > > > > > > > > > > -----Original Message----From: Tami Miller [mailto:tami@fdha.org] Sent: Tuesday, May 08, 2007 12:11 PM To: Clark-Alexander, Barbara Subject: Re: Quick Response Requested from FDHA Barbara, ADHA will email the pre survey memo/letter saying that the survey will be coming. If anyone has a question your information can be listed for any responses (I don't want to field questions about the survey). I am going out of town on Friday and will not be back in the office until Thursday, May 17th. I just talked to ADHA and let them know we would request the email blast next week upon my return. Tami

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192 Appendix B: Expert Panel Survey

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193In this section, you are asked to indicate your willingness to provide dental care to groups of patients. Please indicate how much you agree or disagree with each statement by putting the appropriate number from the rating scale on the line next to the statemen t. If you would like to comment on any statement, please use the space at the end of the questionnaire. Please respond to each st atement using the following scale: PART I Is this item content appropriate to one of the objectives? Is the wording clear ? Yes No No, modify as: Yes No No, modify as: 1. I would be willing to provide dental care for a patient with cerebral palsy who has periodontal disease. 2. I would be willing to provide dental care for a patient who was post myocardial infarction. 3. I would be willing to provide dental care for a person with HIV/AIDS. 4. I would be willing to provide dental care for a patient with severe mental retardation. 5. I would be willing to provide dental care for a wheelchair-bound patient. 6. I would be willing to provide dental care for a patient with a post prosthetic heart valve replacement. 7. I would be willing to provide dental care for a patient with post massive right brain, cerebral vascular infarct. 8. I would be willing to provide dental care for a patient with diabetes. 9. I would be willing to provide dental care for a patient of record with HIV/AIDS. 10. I would be willing to provide dental care for a new patient with HIV/AIDS. 11. I would be willing to provide dental care if a patient told me they were bisexual. 12. I would be interested in an opportunity to work with patients with HIV/AIDS. 13. I would not take care of any patients with mental retardation if given a choice. 14. I would not take care of any patients with Hepatitis B if given a choice. 15. I would not take care of any patient with Hepatitis C if given a choice. 16. I would not take care of any patient with HIV/AIDS if given a choice. 17. I practice in an area/location with a low prevalence of HIV/AIDS, because of the HIV/AIDS epidemic.

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Appendix B (Continued) 194 This section focuses only on HIV disease. Please indicate how much you agre e or disagree with the following statements. PART II Is this item content appropriate to one of the objectives? Is the wording clear ? Yes No No, modify as: Yes No No, modify as: 1. I can identify oral lesions associated with HIV disease. 2. I know the treatments for common HIVrelated oral lesions. 3. I know community resources for people with HIV disease. 4. I can obtain a thorough HIV-risk factor history. 5. I can provide HIV risk-reduction counseling. 6. I use universal precautions. 7. I can educate patients about HIV disease (e.g. transmission, HIV antibody testing, infection control protocol). 8. I can safely provide dental care to persons with HIV disease. 9. I know the CDCs recommendations for protocol after an occupational exposure to HIV. 10. I can effectively provide dental care to persons with HIV disease. Source: Perceived Clinical Ability Scale from J. Driscoll dissertation.

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Appendix B (Continued) 195A professional issue and concern related to managi ng infectious diseases like HIV is the risk of occupational transmission of the virus via various treatment procedures or activities. Please indicate your concern associated with each of the following items. PART III Is this item content appropriate to one of the objectives? Is the wording clear ? Yes No No, modify as: Yes No No, modify as: 1. I feel worried about the possibility of acquiring HIV/AIDS from patients. 2. I worry about possible casual contact with a person with HIV/AIDS. 3. I am fearful of caring for persons with HIV/AIDS because there is no cure. 4. Dental hygienists need to know the HIV antibody status of pa tients they are caring for. 5. It is comforting to know that there isnt much difference in caring for HIV/AIDS patients than caring for other terminally ill persons. 6. I am bothered that I might not be able to prevent myself from contracting HIV/AIDS. Source: NAAS (Nurses AIDS Attitude Scale), Nursing Care Concerns section.

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Appendix B (Continued) 196 Please indicate how much you agree or disagree with the following statements by putting the appropriate number from the following rating scale on the line next to each statement. PART IV Is this item content appropriate to one of the objectives? Is the wording clear ? Yes No No, modify as: Yes No No, modify as: 1.L I would put myself at risk if I work with HIV/AIDS patients. 2.L I would put patients at risk if I work with HIV/AIDS patients. 3.L I would put my family at risk if I work with HIV/AIDS patients. 4.L I would be shunned by my family if I work with HIV/AIDS patients. 5.L I would be shunned by my friends if I work with HIV/AIDS patients. 6.L I would be shunned by my co-workers if I work with HIV/AIDS patients. 7.L I would hurt relations with my partner if I work with HIV/AIDS patients. 8.L I would hurt my future job prospects if I work with HIV/AIDS patients. 9.L Generally speaking, I usually do what my spouse/partner expects me to do. 10.L Generally speaking, I usually do what my family expects me to do. 11.L Generally speaking, I usually do what my close friends expect me to do. 12.L Generally speaking, I usually do what my co-workers expect me to do. 13.L Most people who are important to me think I should care for any person who is HIV+ to whom I am assigned. 14.L Most members of my family think that I should care for any person who has HIV/AIDS to whom I am assigned. 15.L My close friends think that I should care for any person who has HIV/AIDS to whom I am assigned. 16.L My coworkers think that I should care for any person who has HIV/AIDS to whom I am assigned.

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Appendix B (Continued) 197 PART IV CONTINUED Is this item content Is this item content appropriate to one of the objectives? Is the wording clear ? Yes No No, modify as: Yes No No, modify as: 17.L My spouse/partner thinks that I should care for any person who has HIV/AIDS to whom I am assigned. 18.L My boss thinks that I should care for any person who has HIV/AIDS to whom I am assigned. 19.^ I would not treat homosexuals because I am concerned about getting HIV and developing AIDS. 20.^ Patients would leav e the practice I work in if they knew I treat patients with HIV/AIDS. 21.^ Dentists are ethically obligated to treat patients at risk for HIV/AIDS. 22.* I would continue to visit and support a friend who had HIV/AIDS. 23.* I would shake hands with someone who has HIV/AIDS. 24.* HIV/AIDS patients should not be discriminated against in any way. 25.* I would not form a friendship with someone if I knew they had HIV/AIDS. 26.* People with HIV/AIDS should not be allowed to work as dentists or dental hygienists. 27.n I am distressed th at dental procedures have changed because of HIV/AIDS. 28.n Dental hygienists should be allowed to refuse care to persons with HIV/AIDS. 29.m Dental hygienists are ethically obligated to treat patients at risk for HIV/AIDS. 30.m My co-workers do not want to treat HIV/AIDS patients. Source: David Lester article, 1989. L Laschinger, 1993 ^ Kunzel & Sadowsky 1993. m My item. n NAAS

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Appendix B (Continued) 198PART V Finally, this last section requests demographic inform ation which helps to clarif y and enhance the precious information that you provided. Please answer p ractice questions using your primary employer. Your Age: __________ Your Gender: M ___ F ___ Marital Status: ___ 1. Single ___ 2. Married ___ 3. Separated / Divorced ___ 4. Living with partner or significant other ___ 5. Widowed / Widower Years of Education: ___ 1. High school + dental hygiene school ___ 2. 4 year college degree (BA / BS) ___ 3. Post college Year graduated from dental hygiene school ________ Currently practicing: ___ Y ___ N __ Full-time ___ Part-time ___ Salaried ___ Independent Contractor # Years Practicing: _______ Practice Setting Location: ___ Urban ___ Suburban ___ Rural Did you treat HIV/AIDS patients as a dental hygiene student? Y ___ N ___ Have you treated HIV/AIDS patients in private practice? Y ___ N ___ If Yes, how many? ______ Do you know someone who is HIV+ or who has AIDS? Y ___ N ___

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199 Appendix C: Timeline, FDHA Blast, Mail and Email Templates

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200 TIMELINE FOR SURVEY IMPLEMENTATION JANUARY 15 FEBRUARY 23 Contacts / E-mailing and Mailing Dates 7/9 7/12 7/26 8/15 8/31 ________________________________________________________________________ PreThank You / Data Collection Notice Reminder Closed E-mail E-mails and Postcards with survey link E-mail Intro Letter with Final Contact survey link; Thank You / Mail postcards Reminder with survey link E-mails and Postcards with survey link

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Appendix C (Continued) 201 FDHA EMAIL BLAST: Hi, I am Barbara Clark-Alexander, a dental hygiene colleague, and in the next two days, I will be sending you a short on line survey as part of my dissertation requirements. Please fill out the survey to help us all learn more about Florida dental hygienists feelings toward current treatment issues. Study results will be posted on the FDHA listserve. You may reach me at: bclark@hsc.usf.edu ; 813-974-6641. Thanks for your cooperation, and attention to this matter.

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Appendix C (Continued) 202 Mail Templates by Date Mailed 1st template mailed on July 11, 2007: I am asking for your assistance because you are an FDHA member. Recently, FDHA sent you an email blast informing you about a dental hygiene survey. If you have already filled it out, I would like to thank you for participating. If you haven't, won't you take a few minutes to provide us with this very important information? Copy the link below to your browser to begin the survey: http://hsccm2.hsc.usf.edu/us3/Surveys/ TakeSurvey.aspx? surveyid=1225, Remember to hit "Submit" at the end. Study results will be posted on the FDHA listserve. You may reach me at: bclark@hsc.usf.edu ; 813-974-6641. Thanks again. 2nd template mailed on July 24, 2007: I am Barbara Clark-Alexander, a colleague, and I need your help I am surveying Florida dental hygienists thoughts toward current treatment issues, and am looking forward to hearing what you have to say. Thank you in advance if you completed and returned the email survey that was sent to you recently. If not, Copy the link below to your browser to begin the survey: http://hsccm2.hsc.usf.edu/us3/Surveys/ TakeSurvey.aspx? surveyid=1225 Thank you for taking the 5-10 minutes to do this for me. You may reach me at: bclark@hsc.usf.edu; 813-974-6641. 3rd template mailed on August 13,2007: Final Reminder HELLO! This is Barbara Clark-Alexander, an FDHA colleague, asking you one last time to fill out the online dental hygiene Survey by: Copying the link below to your browser to begin the survey: http://hsccm2.hsc.usf.edu/us3/Surveys/ TakeSurvey.aspx? surveyid=1225 When you have completed it, click "Submit" at the end. The online survey will be available until August 31, 2007. Thanks very much if you have already replied as I am most appreciative. You may reach me at: bclark@hsc.usf.edu ; 813-974-6641.

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Appendix C (Continued) 203 Email Templates by Date Sent 1st email sent on July 12, 2007: I am asking for your assistance because you are an FDHA member. Recently, FDHA sent you an email blast informing you about a dental hygiene survey. If you have already filled it out, I would like to thank you for participating. If you haven't, won't you take a few minutes to provide us with this very important information? Copy the link below to your browser to begin the survey: http://hsccm2.hsc.usf.edu/us3/Surveys/ TakeSurvey.aspx? surveyid=1225, Remember to hit "Submit" at the end. Study results will be posted on the FDHA listserve. You may reach me at: bclark@hsc.usf.edu ; 813-974-6641. Thanks again. 2nd email sent on July 26, 2007: I am Barbara Clark-Alexander, a colleague, and I need your help I am surveying Florida dental hygienists thoughts toward current treatment issues, and am looking forward to hearing what you have to say. Thank you in advance if you completed and returned the email survey that was sent to you recently. If not, Copy the link below to your browser to begin the survey: http://hsccm2.hsc.usf.edu/us3/Surveys/ TakeSurvey.aspx? surveyid=1225 Thank you for taking the 5-10 minutes to do this for me. You may reach me at: bclark@hsc.usf.edu; 813-974-6641. 3rd email sent on August 15,2007: Final Reminder HELLO! This is Barbara Clark-Alexander, an FDHA colleague, asking you one last time to fill out the online dental hygiene Survey by: Copying the link below to your browser to begin the survey: http://hsccm2.hsc.usf.edu/us3/Surveys/ TakeSurvey.aspx? surveyid=1225 When you have completed it, click "Submit" at the end. The online survey will be available until August 31, 2007. Thanks very much if you have already replied as I am most appreciative. You may reach me at: bclark@hsc.usf.edu ; 813-974-6641.

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Appendix C (Continued) 204

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205 Appendix D: Letter of Consent / Survey

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206 Dear Dental Hygiene Colleagues, I am Barbara Clark-Alexander, RDH, BS MPH, and I am working on a PhD degree in Community and Family Heal th Studies at the University of South Florida under the direction of R obert J. McDermott, Ph.D. This survey is part of the research for my dissertation in which I am investigating precautions and risks related to infectious disease issues. As a dental hygenist who is a member of the Florida Dental Hygienists' Association, I am writi ng to ask for your help. This research study explores beliefs, attitudes and intentions of dental hygienists to treat selected groups of patients with infectious diseases, and examines the relationships between intentions and other variables that may impact their intentions to treat these patients. Your participation is voluntary. You are not required to sign an informed consent form as your participation provides such consent, and no health, financial, professional, or em ployment risks to you are posed. Your completed survey responses w ill be received by the Information Services Department of USF Health. Only my research committee of five faculty members and I will be perm itted to see these responses. Be assured that your responses are conf idential and all i dentifiers related to you will be removed prior to data analysis. Moreover, only aggregate statistics will be generated. The findi ngs will benefit the practice of dental hygiene in caring for patients with infectious disease. Results will be shared with participants through t he Florida Dental Hygienists' Association listserv at the conclusion of the study. The findings also will be submitted for publication cons ideration in the Journal of the American Dental Hygienists' Associ ation, American Journal of Public Health, Florida Public Health Re view, Access, and the Florida Dental Association Journal. The more responses I receive, the m ore reliable the research will be. Therefore, I ask that you please take l0 minutes to complete this brief online questionnaire (see link below). In the event that you are employed in more than one dental practice, please respond to the following questions with what you c onsider your primary practice in mind. If you have any questions, feel free to contact me at (813) 974-6641 or email me at bclark@health.usf.edu. Again, thank you for your participation. I appreciate your assistance i n helping to understand important factors that impac t dental hygiene practice.

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Appendix D (Continued) 207 PART I In this section, you are asked to indicate your willingness to provide dental hygiene care to groups of patients. Please indicate how much you agree or disagree with each statement by putting the appropriate number from the rating s cale on the line next to the statement. If you would like to comment on any statement, please use the space at the end of the questionnaire. Please respond to each statement using the following scale: 1. Strongly Agree 2. Agree 3. Neither Agree nor Disagree / Uncertain 4. Disagree 5. Strongly Disagree ___ 1. I would be willing to provide dent al hygiene care for a person with HIV/AIDS. ___ 2. I would be willing to provi de dental hygiene care for a patient of record with HIV/AIDS. ___ 3. I would be willing to provi de dental hygiene care for a new patient with HIV/AIDS. ___ 4. I would be willing to provi de dental hygiene care if a patient told me he/she was bisexual. ___ 5. I would be interested in an opportunity to treat patients with HIV/AIDS in my current work setting. ___ 6. I would take care of any patient with Hepatitis B. ___ 7. I would take care of any patient with Hepatitis C. PART II This section focuses only on HIV disease. Please indicate how much you agree or disagree with the following statements. 1. Strongly Agree 2. Agree 3. Neither Agree nor Disagree / Uncertain 4. Disagree 5. Strongly Disagree ___ 1. I can identify oral lesions associated with HIV disease. ___ 2. I know the treatments for comm on HIV-related oral lesions. ___ 3. I know community resources for people with HIV disease. ___ 4. I can obtain a thorough medical hist ory including HIV risk factors. ___ 5. I can provide HIV risk-reduction counseling. ___ 6. I use universal precautions.

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Appendix D (Continued) 208 ___ 7. I feel professionally prepared to ed ucate patients about HIV disease (e.g. transmission, HIV antibody testi ng, infection control protocol). ___ 8. I can safely provide dental hygiene care to persons with HIV disease. ___ 9. I know the CDCs recommendations fo r protocol after an occupational exposure to HIV. ___ 10. I can effectively provide dental hygie ne care to persons with HIV disease. PART III A professional issue and concer n related to managing infecti ous diseases like HIV is the risk of occupational transmi ssion of the virus via various treatment procedures or activities. Please indicate your concern a ssociated with each of the following items. 1. Strongly Agree 2. Agree 3. Uncertain 4. Disagree 5. Strongly Disagree ___ 1. I feel worried about the possibility of acquiri ng HIV/AIDS from patients. ___ 2. I worry about possible casual contact with a person with HIV/AIDS. ___ 3. I feel that dental hygie nists need to know the HI V antibody status of patients they are caring for. ___ 4. I worry that the infection control procedures used in our office will not protect me from acquiring HIV/AIDS on the job. PART IV Please indicate how much you agree or disagree with the following statements by putting the appropriate number from the following rating scale on the line next to each statement. 1. Strongly Agree 2. Agree 3. Uncertain 4. Disagree 5. Strongly Disagree ___ 1. I would be putting myself at risk if I treated HIV/AIDS patients. ___ 2. I would be putting other patients at risk if I work with HIV/AIDS patients. ___ 3. I would be putting my family at risk if I work with HIV/AIDS patients. ___ 4. The attitude of my family affect s my decision to work with HIV/AIDS patients. ___ 5. The attitude of my friends affect s my decision to work with HIV/AIDS patients.

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Appendix D (Continued) 209 ___ 6. I would hurt my future job prospects if I work with HIV/AIDS patients. ___ 7. My boss thinks that I should provi de dental hygiene care for any person who has HIV/AIDS. ___ 8. I would prefer not to treat homose xual patients because I am concerned about getting HIV and developing AIDS. ___ 9. I would shake hands with someone who has HIV/AIDS. ___ 10. People with HIV/AIDS should not be allowed to work as dentists or dental hygienists. ___ 11. Dental hygienists should be allowed to refuse to provide dental hygiene care to persons with HIV/AIDS. ___ 12. My co-workers do not want to treat HIV/AIDS patients. ___ 13. I feel that I am at risk of contrac ting HIV due to personal lifestyle practices. PART V Demographics Finally, this last section requests demogra phic information which helps to clarify and enhance the precious information that you pr ovided. Please answer practice questions using your primary employer. Your Age: __________ Your Gender: M ___ F ___ Marital Status: ___ 1. Single (check one) ___ 2. Married ___ 3. Separated / Divorced ___ 4. Living with partner or significant other ___ 5. Widowed / Widower Race: ___ 1. White (Caucasian) ___ 2. Black / African American (not Hispanic) ___ 3. Hispanic / Latino (Black or White) ___ 4. Asian ___ 5. Native Hawaiian / Other Pacific Islander ___ 6. American Indian / Alaskan Native ___ 7. More than one race ___ 8. Unknown Education: ___ 1. Dental Hygiene Diploma (check highest ___ 2. Associate Degree (e.g. AA, AS) achieved) ___ 3. Bachelor Degree (e.g. BA, BS) ___ 4. Post Baccalaureate Degree (e.g. Masters or higher degree)

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Appendix D (Continued) 210 Year graduated from dent al hygiene program ________ Years in Practice ________ Currently practicing: ___ Full-time ___ Part-time ___ Not Practicing Did you treat HIV/AIDS patients as a de ntal hygiene student? ___ Y ___ N Have you treated HIV/AIDS patients in private practice? ___ Y ___ N Do you have a friend or family me mber who has HIV/AIDS? ___ Y ___

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211 Appendix E: IRB

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212

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213 Appendix F Data Analysis Plan

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214Table 3.2 Data Analysis Plan: Research Variables, Data Points, Variable Descriptions, Type of Data Analysis to be Performed Research Questions Data/Variables Type of Variables Description Analysis 1. What are dental hygienists stated intentions, attitudes, perceived risk, perceived self efficacy and normative beliefs toward treating HIV/AIDS patients? Int 1-7 Self 8-17 Risk 18-21 Att 22-24,27,29,30,34 Norm 25-26,28,31-33 Independent / Dependent Ordinal Univariate analysis of variables: Int1-7 Self 8-17 Risk 18-21 Att 22-24,27,29,30,34 Norm 25-26,28,31-33 2. What is the association between dental hygienists intentions to treat and perceived self efficacy, perceived risk of being infected, attitudes and normative beliefs toward treating HIV/AIDS patients? Int scale score Self scale score Risk scale score Att scale score Norm scale score Independent / Dependent Ordinal Spearman correlation coefficient Int scale score x Self scale score Int scale score x Risk scale score Int scale score x Att scale score Int scale score x Norm scale score 3. Is there an association between Years in Practice and intention to treat HIV/AIDS patients? 41-Years in practice; Int scale score Independent / Dependent Continuous / Ordinal Spearman correlation coefficient 4. Is there an association between Ever Treated an HIV+ patient as a student, and intention to treat HIV/AIDS patients? 43Ever treated an HIV+ patient as a student; Int scale score Independent / Dependent Nominal / Ordinal Kruskal-Wallis test for > 2 groups 5. Is there an association between Ever Treated an HIV+ patient in private practice, and intention to treat HIV/AIDS patients? 44Ever treated an HIV+ patient in private practice; Int scale score Independent / Dependent Nominal / Ordinal Kruskal-Wallis test for > 2 groups

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215Table 3.2 (Continued) Research Questions Data/Variables Type of Variables Description Analysis 6. Is there an association between Knowing a friend or family member with HIV/AIDS, and intention to treat HIV/AIDS patients? 45Knowing a friend or family member with HIV/AIDS; Int scale score Independent / Dependent Nominal / Ordinal Mann Whitney rank sum test with 2 samples 7. What is the measure of association between dental hygienists intentions to treat, and perceived self efficacy, perceived risk of being infected, attitudes and normative beliefs toward treating HIV/AIDS patients? Int scale score Self scale score Risk scale score Att scale score Norm scale score Potential confounders: Age, years in practice, treated as a student, treated in private practice, knowing person Dependent / Independent Ordinal / Nominal / Continuous Multiple linear regression

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216 Appendix G South Carolina Boar d of Dentistry / FTC Decision

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217Message: 2 Date: Wed, 27 Jun 2007 21:27:17 -0400 From: sebok@aol.com Subject: Re: [DPH] FYI -FTC consent order with SC State Board of Dentistry To: tbyrdrdh@aol.com, Nicholas.Mosca@msdh.state.ms.us, members@astdd.org, dental-public-health@list.pitt.edu Message-ID: <8C9873A992E1BD2-1164-299F@FWM-M30.sysops.aol.com> Content-Type: text/plain; charset="utf-8" No matter which side each of us reading this news may have taken on this issue, ultimately, it is a total win for the people we are all committed to serving!! I commend Tammy Byrd on her long, and probably, very lonely road throughout all of this................ Now, let's all move on to other barriers to improved access to care and maybe, just maybe, it'll all look much better soon! Best, Mary Ellen Yankosky Boston, MA -----Original Message----From: tbyrdrdh@aol.com To: Nicholas.Mosca@msdh.state.ms.us; members@astdd.org; dental-publichealth@list.pitt.edu Sent: Tue, 26 Jun 2007 11:20 pm Subject: [DPH] FYI -FTC consent order with SC State Board of Dentistry http://www.ftc.gov/opa/2007/06/dentists.shtm South Carolina Board of Dentistry Settles Charges That it Restrained Competition in the Provision of Preventive Care by Dental Hygienists FTC Complaint Alleged Conduct Limited Needy Childrens Access to Care The Federal Trade Commission today announced a consent order settling charges brought in September 2003 that the South Carolina State Board of Dentistry unlawfully restrained competition in violation of Section 5 of the FTC Act by adopting a rule that required a dentist to examine every child before a dental hygienist could provide preventive care such as cleanings in schools. The Board adopted the rule in 2001, after the South Carolina legislature had eliminated a statutory requirement that a dentist examine

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Appendix G (Continued) 218each child before a hygienist could perform preventive dental care in schools. The Board is a state regulatory agency, composed primarily of practicing dentists, that licenses and regulates dentist and dental hygienists. The FTC alleged that the Boards anticompetitive conduct led to fewer children receiving preventive dental care in schools particularly economically disadvantaged children. As a result of legislation enacted by the South Carolina legislature in 2003, the Board no longer requires a dentist to examine each child before a hygienists exam in a public health setting. The consent order requires the Board to publicly announce its support for the current state policy that hygienists can provide such care in public health settings without a dentists examination and to notify the Commission before adopting rules or taking other actions related to preventive dental services provided by dental hygienists in public health settings. As this case reflects, state regulatory boards that restrict competition in ways not contemplated by state law are subject to the antitrust laws, said Jeffrey Schmidt, Director of the FTCs Bureau of Competition. This case is important because it protects access to preventive dental services for children especially those from lowincome families in schools. Terms of the Consent Order The Commissions consent order has two main features. First, it requires the Board to affirm and publicize its support for the state legislative policy that prevents the Board from requiring a dentist examination as a condition of dental hygienists providing dental care in public health settings. The order requires the Board to post the announcement on its website and publish it in its newsletter, as well as to distribute it to every licensed dentist and dental hygienist in South Carolina, as well as to new licensees for the next three years. It also requires the Board to send the announcement to all school district superintendents within the state. The Boards announcement supporting the legislative policy can be found in Appendix A of the consent order on the FTCs website. Second, to prevent similar anticompetitive conduct in the future, the order requires the Board to provide written notice to the Commission prior to the promulgation of any proposed or final rule, regulation, policy, issuance of a Based on various factors particular to this case, the Commission has determined that it is not necessary to include a cease and desist provision that directly prohibits the Board from resuming its past conduct. Thus, the order will increase the FTCs ability to monitor the Boards future conduct, and is likely to help deter the Board from imposing similar restraints on public health preventive dental care in the future. The order expires in 10 years. Case History In 2000, the South Carolina legislature eliminated a statutory requirement that a dentist examine each child before a hygienist could

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Appendix G (Continued) 219perform preventive dental care in a public health setting. The goal was to allow schoolchildren, particularly those from low-income families, to receive preventive dental care. In July 2001, however, the Board adopted an emergency regulation that re-imposed the dentist examination requirement. As a result of the Boards actions, a hygienist-owned company that had begun sending hygienists to schools to provide preventive care was forced to change its business model and was able to serve far fewer patients. The Boards emergency regulation expired in six months, in January 2002. By that time, however, the Board had published a proposal to adopt the dentist examination requirement as a permanent regulation. After a state administrative law judge ruled that the Boards proposed regulation was unreasonable and contrary to state policy, the Board abandoned its attempt to make the regulation permanent. The state legislature subsequently enacted legislation in May 2003 expressly providing that examinations by a dentist are applicable in some settings when dental hygienists provide preventive care, but they are not required in public health settings under the direction of the state health department. In July 2004, the Commission denied the Boards motion to dismiss the Boards complaint based on the Boards assertion that its actions were protected by the state action doctrine. The Commission, however, held the Boards motion to dismiss in abeyance pending discovery on factual issues relating to the risk of recurrence of the challenged conduct. The Board filed an appeal with the United States Court of Appeals for the Fourth Circuit seeking an interlocutory review of the Commissions state action ruling, and the Commission stayed discovery during the pendency of the Boards appeal on state action. In May 2006, the Court of Appeals dismissed the appeal for lack of jurisdiction. In January 2007, the Supreme Court denied the Boards petition for certiorari seeking review of the appellate courts dismissal of the appeal. The Commission vote approving the complaint and consent order was 5-0. The order will be subject to public comment for 30 days, until July 19, 2007, after which the Commission will decide whether to make it final. Comments should be sent to: FTC, Office of the Secretary, 600 Pennsylvania Ave., N.W., Washington, DC 20580. NOTE: A consent agreement is for settlement purposes only and does not constitute an admission of a law violation. When the Commission issues a consent order on a final basis, it carries the force of law with respect to future actions. Each violation of such an order may result in a civil penalty of $11,000. Copies of the complaint, consent order, and analysis to aid public comment are available now on the FTCs Web site. The FTCs Bureau of Competition works with the Bureau of Economics to investigate alleged anticompetitive business practices and, when appropriate, recommends that the Commission take law enforcement action. To inform the Bureau about particular business practices, call 202-326-3300, send an e-mail to antitrust@ftc.gov, or write to the Office of Policy and Coordination, Room 394, Bureau of Competition, Federal Trade

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Appendix G (Continued) 220Commission, 600 Pennsylvania Ave, N.W., Washington, DC 20580. To learn more about the Bureau of Competition, read Competition Counts at http://www.ftc.gov/competitioncounts MEDIA CONTACT: Mitchell J. Katz Office of Public Affairs 202-326-2161 STAFF CONTACT: Gary H. Schorr Bureau of Competition Tammi O. Byrd, RDH CEO/Clinical Director Health Promotion Specialists 803-348-2973 803-407-7938 (fax) CONFIDENTIAL & PRIVILEGED Unless otherwise indicated or obvious from the nature of the above communication, the information contained herein is privileged and confidential information/work product. The communication is intended for the use of the individual or entity named above. If the reader of this transmission is not the intended recipient, you are hereby notified that any dissemination, distribution or copying of this communication is strictly prohibited.

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221 Appendix H: ADHA Supervision / Direct Access Documents

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222States with General Supervision in the Private Office The following states have general supervision in the private office. General supervision means that the dental hygienist may treat patients when the dentist is not present, based on some type of authorization by the dentist. However, the elements of general supervision vary by state. See below for a description of the requirements in each state. Note that almost every stateeven those without general supervision in the private office, have some provision for dental hygienists to provide services in some settings outside of the office under general supervisionor even allow dental hygienists direct access to patients in certain settings. Typically out of dental office supervision in the states listed below will be less restrictive than in-office supervision. AK dentist has authorized the procedures and they are being carried out in accordance with the dentist's diagnosis and treatment plan AR (definition from the rules) only with the expressed consent of the supervising dentist and only for brief intervals when the supervising dentist cannot be in the treatment facility not to exceed two (2) consecutive days; written protocols for emergencies as established by the supervi sing dentist.; hygienists must have one (1) full year of full-time experience, patients must be notified in advance; supervising dentist must have examined the patient(s) not more than twelve (12) months prior. AZ is available for consultation, whether or not the dentist is in his office, over procedures which the dentist has authorized and for which the dentist remains responsible. CA supervision of dental procedures based on instructions given by a licensed dentist (Must at least briefly examine new patients one time before services) CO requires the tasks be performed with the prior knowledge and consent of the dentist CT performed with the knowledge of said licensed dentist DC based on instructions given by a licensed dentist DE authorizes the work to be performed. Emergency care and consultant services are provided by an "on-call" dentist not present in the treatment facility, if the primary dentist is not present. FL supervision whereby a dentist authorizes the procedures which are being carried out but need not be present. The rules add that a licensed dentist examine the patient, and diagnose a condition to be treated.

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Appendix H (Continued) 223IA (rule defines supervision) a dentist has examined the patient and has prescribed authorized services to be provided by a dental hygienist. The dentist need not be present ID dentist authorize the procedure which is carried out, but not requiring that a dentist be in the office IL a dentist authorize the procedures which are being carried out, but not requiring that a dentist be present In the dental office the patient must have been examined by the dentist within one year of the provision of dental hygiene services, the dentist has approved the dental hygiene services by a notation in the patient's record and the patient has been notified that the dentist may be out of the office during the provision of dental hygiene services. KS dentist may delegate verbally or by written authorization the performance of a service, task or procedure to a licensed dental hygienist under the supervision and responsibility of the dentist, if the dental hygienist is licensed to perform the function, and the supervising dentist examines the patient at the time the dental hygiene procedure is performed, or during the 12 calendar months preceding the performance of the procedure KY the dentist has authorized a specific dental service or procedure but is not necessarily physically present. LA dentist has authorized procedures which are being carried out according to dentists treatment plan. MA based on instructions given by a licensed dentist MD dental hygienist has at least 1,500 hours clinical practice; there is a written agreement between the supervising dentist and the dental hygienist with terms under which the dental hygienist may practice; notation of general supervision in the patient's records; dentist has examined and evaluated patient and prescribed and authorized. within prior 7 months; patient gives informed consent to general supervision; therere written emergency procedures in which RDH is trained; designated dentist is available for consultation; hygienist may only work under general 60% of time she practices and supervising dentist may not employ more than two dental hygienists under general supervision at any given time. ME Rule dentist is not required to be in the dental office at the time the procedures are being performed on a patient of record. MI

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Appendix H (Continued) 224A dentist has designated a patient of record upon whom services are to be performed and has described the procedures to be performed MO Rules dentist has authorized the procedure for a patient of record; patient informed that the dentist is not in the treatment facility; authorization written in the patients record and is valid from the date of the most recent examination for a maximum of twelve (12) months. MN Rules dentist has authorized the procedures and they are being carried out in accordance with the dentist's diagnosis and treatment plan. MT treatment provided with the intent and knowledge of the dentist ND 43-20-03. only for patient of record examined within the past twelve months; a current treatment plan is in place; and any delegated procedure is preauthorized by the supervising dentist. NE directing of the authorized activities of a dental hygienist NH (definition in rules) dentist has authorized the procedures, and the procedures are being carried out in accordance with their diagnosis and treatment plan, and the procedures will be personally evaluated and reviewed by the dentist with the patient at least once in a 12 month period. NM authorization by a dentist of the procedures to be used and the execution of the procedures in accordance with the a dentists diagnosis and treatment plan NV may perform only the services which are authorized for to a person who is a patient of the dentist who authorized the performance of those services. NY (definition in the rules) a supervising dentist is available for consultation, diagnoses, and evaluation, has authorized the dental hygienist to perform the services, and exercises that degree of s upervision appropriate to the circumstances. OH A dental hygienist may provide, for not more than fifteen consecutive business days, dental hygiene services to a patient when the supervising dentist is not physically present IF hygienist has at least two years and a minimum of three thousand hours of experience ; completed a course approved by the state dental board in the identification and prevention of potential medical emergencies; complies with written protocols for emergencies the supervising dentist establishes.; does not perform procedures while the patient is anesthetized, definitive root planing, definitive subgingival curettage, dentist has evaluated the dental hygienist's skills;

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Appendix H (Continued) 225has examined the patient not more than seven months prior ; hygienist complies with written protocols or written standing orders that the supervising dentist establishes; dentist completed and evaluated a medical and dental history of the patient not more than one year prior ; dentist determines that the patient is in a medically stable condition. OK dentist has previously diagnosed the condition to be treated, personally authorizes the procedures, and will evaluate the progress of the dental treatment within a reasonable time as determined by the nature of the procedures performed, the needs of the patient, and the professional judgment of the supervisory dentist. Authorization for general supervision is at the discretion of the supervisory dentist and limited to a maximum of thirteen (13) months following examination by the supervisory dentist of a patient of record. OR dentist authorize the procedures PA At the present time, in a dental facility requires a dentist examine the patient, develop a dental treatment plan, authorize the performance of dental hygiene services to be performed within 90 days of the examination, and take full professional responsibility for the performance of the dental hygienist for patients who fall under ASA Class I only supervision (American Society of Anesthesiologists classification for a patient without systemic disease) However, a recent law change will do away with ASA classifications. The new definition, which doesnt take effect for a couple of months, reads: "general supervision" means supervision by a dentist who examines the patient, develops a dental treatment plan, authorizes the performance of the radiologic services to be performed within one year of the examination, and takes full professional responsibility for performance of the dental hygienist RI from the rules dentist has authorized the procedure/duty and such is being carried out in accordance with his/her diagnosis and treatment plan. SC Authorized" means the supervising dentist in a private office setting has personally approved the procedures to be performed and is responsible for the care provided to the patient. A dentist in a private office setting may authorize general supervision only if a new patient of record must is examined during the initial visit; an appointed patient is examined by at a minimum of twelve-month intervals and appointed patient is notified in advance he or she will be treated by the dental hygienist under general supervision

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Appendix H (Continued) 226SD dentist authorize the procedures to be carried out, and that the patient to be treated is a patient of record of the supervising dentist and has had a complete evaluation within the previous thirteen months of the delegation of procedures; TN the dentist has personally diagnosed the condition to be treated, has personally authorized the procedures being performed and will evaluate the performance of the dental hygienist. TX dentist may delegate orally or in writing a service, task, or procedure to a dental hygienist who is under the supervision and responsibility of the dentist, if: dentist examines the patient: at the time the procedure is performed or (B) during the 12 calendar months preceding UT the supervising dentist is available for consultation regarding work the supervising dentist has authorized VA a dentist has evaluated the patient and prescribed authorized services to be provided VT dentist agreeing to procedures or treatment performed by appropriate personnel and being available for consultation. WA procedures based on examination and diagnosis of the patient and subsequent instructions given by a licensed dentist WI requires a written or oral prescription, dentist has examined the patient at least once during the 12-month period immediately preceding, prescription specifies the practices and procedures that the dental hygienist may perform, if performed in a dental office, the patient has been the dentist's patient of record for not less than 6 months. WY (definition in rules) dentist has diagnosed and authorized the procedures which are being carried out; however, a dentist need not be present Citation: ADHA. (June, 2007). Provision of governmental affairs chart.

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Appendix H (Continued) 227

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Appendix H (Continued) 228

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Appendix H (Continued) 229

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Appendix H (Continued) 230

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Appendix H (Continued) 231

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Appendix H (Continued) 232

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Appendix H (Continued) 233

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Appendix H (Continued) 234

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Appendix H (Continued) 235

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Appendix H (Continued) 236

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Appendix H (Continued) 237

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238 Appendix I: Personal Communication

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239 From: KanWatsu@aol.com Sent: Thursday, July 12, 200 76:30 PM To: Clark-Alexander, Barbara Subject: Re: Invitation to take the Dental Hygienists I Treating HIV I AIDS Patients S ... Greetings Ms Clark, RDH I am impressed that you are conducting this research and using this survery to assist with treatment for those that need it, no matter what their health status; as they need it the most! I remember when this disease was first "discovered and named" and the 'stigma' that followed. I have compassion for allthose infected and those in our profession that choose not to treat. May there be more of us that do choose to provide dental hygiene services. Good luck on furthering your education and assisting those that need our services. Sincerely, Rev Kanela Barton, RDH

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About the Author Barbara Clark-Alexander received her B achelor of Science in Dental Hygiene Public Health from the University of Minne sota in 1978. After moving to Florida, she coordinated clinical trial studies for the National Institutes of Health and Colgate Palmolive Company, and received a Maste rs Degree in Public Health from the University of South Florida in 1989. In 1990, she joined the Florida Health Information Center USF where she managed studies on aging, Medicaid managed car e, full service schools, adolescent risk behaviors, and the Florida Family AIDS Network. During her doctoral studies, Ms. ClarkAlexander was an instructor and guest speaker for both graduate and undergraduate courses at the USF COPH, and continuing education courses in HIV/AIDS to dental pr ofessionals. She is currently a member of: the Ryan White Care Council and numerous advisory committees. She has been the recipient of a Florida Public Health Asso ciation scholarship, a nd student scholarship awards at the COPH.


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Dental hygienists' beliefs, norms, attitudes, and intentions toward treating HIV/AIDS patients
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ABSTRACT: There is a great demand and need for oral health care during the course of HIV disease (HIV Costs and Services Utilization Study; Marcus et. al., 2005). HIV+ patients identified three key barriers to obtaining oral health treatment: 1) beliefs and attitudes of dental health care providers (DHCPs) may have lead to their unwillingness to treat HIV/AIDS patients; 2) the existence of racial and ethnic disparities in health care in the United States, and 3) how DHCPs perceive their risk of contracting HIV. The fear and stigma associated with treating patients with HIV further compromises their access to care and their health status. Oral health conditions associated with HIV disease are frequently more severe than those of the general population, making access to both dental and medical care imperative. Plus, Florida has some of the highest numbers of HIV/AIDS patients in the nation.This study was descriptive, cross-sectional and used quantitative methods to explore the dental hygienists' behavioral and normative beliefs, attitudes, and intentions toward treating patients with HIV/AIDS. A three-phase pilot study was conducted to assess the validity and reliability of the survey instrument. An email delivery method was used to implement the survey, and a 22% response rate was achieved (n=219). The majority of respondents were female (96%), white (89%), married (77%), currently working (86%), and had treated HIV/AIDS patients in private practice (80%). Bivariate analysis showed that dental hygienists' intentions toward treating HIV/AIDS patients were significantly associated with five independent variables, and binary logistic regression confirmed the significance of two of these associations.Overall, study participants indicated that they were willing to, and had positive attitudes toward, clinically treating HIV/AIDS patients; they were confident in their ability to treat them, and their normative beliefs did not hinder their intention to do so, and they did not worry about acquiring HIV in the workplace. Three recommendations were made: increase access to oral health care for HIV/AIDS patients within community settings by removing barriers to care, incorporate cultural/sensitivity training in all dental/dental hygiene school curriculums, and mandate Florida HIV/AIDS continuing education requirements every biennium for dentists and dental hygienists.
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