HIV & AIDS Review 12 (2013) 1422

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HIV & AIDS Review

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Original research article

Bidan cantik: Psychoeducation on HIV and AIDS to improve the service quality
of midwives at Yogyakarta public health center
Andrian Liem a,b, , Maria G. Adiyanti a
a
Magister of Profesional Psychology, Faculty of Psychology, University of Gadjah Mada, Yogyakarta, Indonesia
b
Faculty of Psychology, University of Ciputra, Surabaya, Indonesia

a r t i c l e i n f o a b s t r a c t

Article history: Background: Midwives play a signicant role in preventing HIV transfusion from mother to child since
Received 5 December 2012 they directly deal with prospective mothers and pregnant women. However, it is considered that the
Received in revised form 7 February 2013 quality services of midwives have not met the maximum standards.
Accepted 8 February 2013
Aim: To improve the quality service of midwives stationed at public health center through psychoe-
ducation on HIV and AIDS based on Safer practices-Available Medication-VCT-Empowerment (SAVE)
Keywords:
approach, referred to BIDAN Cerdas dan Empatik (CANTIK) program (Smart and Emphatic Midwives
Health psychology
program).
HIV and AIDS psychoeducation
PMTCT
Materials and methods: Action research with quasi experiment method using non-random untreated
SAVE control group design with dependent pretest and posttest samples. The participants were 24 midwives
Midwives working at public health center. The research instruments used were HIV knowledge test, negative
attitude towards HIV scale, emphatic and caring consultation (ECC) observation sheet, and HIV social-
ization. Quantitative analysis was conducted through mixed design ANOVA and qualitative analysis was
conducted in the form of narrative description.
Results and conclusion: BIDAN CANTIK psychoeducation program might improve the quality service of
midwives at public health center. It was due to the improvement of knowledge on HIV. However,
BIDAN CANTIK psychoeducation program did not signicantly decrease negative attitude towards HIV
and improve ECC. BIDAN CANTIK psychoeducation program was not succeeded in encouraging midwives
to socialize HIV and AIDS to the patients of Health of Mother and Children Polyclinic. One of the obsta-
cles in reducing negative attitude of midwives and in encouraging them to socialize HIV and AIDS was
socio-cultural factor.
2013 Polish AIDS Research Society. Published by Elsevier Urban & Partner Sp. z o.o. All rights reserved.

1. Introduction
Women and children were vulnerable to HIV and AIDS infec-
tions [14]. According to WHO, without prevention effort, the risk
percentage of MTCT could reach 40% [5]. Midwives play impor-
tant role in preventing MTCT of HIV. The key-role of midwives was
embodied in promotion of rights and reproduction health in order
to prevent sexually transmitted diseases, including HIV and AIDS
[510]. The advantage of midwives in comparison to other health
profession was the high intensity of interaction between midwives
and prospective mothers or pregnant women so that they might
become the main source of information about health, including HIV
and AIDS transmission and prevention [7,11]. Therefore, midwives
Corresponding author at: UC Town, Citraland, Surabaya 60219, Indonesia.
Tel.: +62 899 5084594.
E-mail addresses: andrianliem@yahoo.com, mynameliem@gmail.com (A. Liem).
need to have deeper understanding about HIV and AIDS and con-
stantly update their knowledge on the topic [1214].
The fact stated differently. During initial interview (September
2011; March 2012) conducted by researcher throughout ve public
health centers (PHC) in Sleman District, the midwives who mostly
were diploma graduates stated that material on HIV and AIDS had
only been taught briey to them in class.
There was only one time in class in which the lecturer taught
us about sexually transmitted diseases. It was during health
reproduction class. (S, 27 years old)
The nding was in accordance to the result of Focused Group
Discussion (FGD) attended by midwives in Jakarta in which they
felt that they were lacking in knowledge on PMTCT of HIV and
AIDS and some of them even had never been taught about it [15].
The condition was a predictor of midwives lack of knowledge on
HIV and AIDS, low self condence in midwives to socialize HIV and
AIDS issues to patients of Health of Mother and Children Polyclinic
(HMCP) [7,16].

1730-1270/$ see front matter 2013 Polish AIDS Research Society. Published by Elsevier Urban & Partner Sp. z o.o. All rights reserved.
http://dx.doi.org/10.1016/j.hivar.2013.02.001
 A. Liem, M.G. Adiyanti / HIV & AIDS Review 12 (2013) 1422
The result of discussion between the researcher and 16 mid-
wives in Sleman District (JanuaryApril 2012) showed that those
midwives tend to refuse to take care of patient that was suspected
as being infected by HIV. They would instantly refer the suspected
patient to Hospital due to fear of contracting the disease.
If the medical chart showed that the patient always relapsed,
and then there was infection around the genital area, we
instantly referred the patient to Sardjito to do a VCT. We do not
know if the patient is positive, but it is better than contracting
the disease. (R, 39 years old)
The nding was similar to results of previous studies [1720],
which stated that knowledge and misinformation on HIV causes
negative attitude and discriminative behavior by health work-
ers towards people with HIV. Effect of knowledge and attitude
altogether was 5% towards reduction of discriminative behaviors
meanwhile contribution of knowledge towards attitude was 39%
[21]. Knowledge on HIV is related to the attitude towards people
with HIV [22]. The right knowledge on HIV and AIDS would cor-
relate positively with emphatic attitude towards people with HIV
and to preventive behavior towards exposure during practice. Mid-
wives who understand modes of HIV transmission have low stigma
towards people with HIV [2325].
The result was in accordance to Planned Behavior Theory which
stated that the decision to display certain behavior is the result
of rational process that is directed towards certain purposes and
following sequences of thinking [26,27]. Planned behavior or a
persons intention could be predicted through his/her attitude. Atti-
tude is dened as positive or negative evaluation towards various
aspects in social world [28].
On the other hand, midwives are also health workers who are
vulnerable to various modes of HIV transmission. They carry larger
risk of HIV transmission from patient to midwife during birthing
process than surgeon since midwives are exposed more intensively
to body uid and they used health instrument such as syringe more
often than surgeon [1,24,2931]. Based on the result of FGD with
midwives working at Prambanan PHC (April 2012), it was found
that all midwives had experienced exposure to syringe, starting
from the moment they open the cap of the syringe up until the
moment they put the cap back on when they were nished using
it.
The condition above is not included in the prevention pro-
gram of HIV epidemic using AbstinenceBe faithfuluse Condom
(ABC) approach. Therefore, an African network of religious leader
infected by HIV or live with people with HIV, ANERELA+, developed
and introduced a brand new approach that was more comprehen-
sive referred to as Safer practicesAvailable medicationVoluntary
counseling and testingEmpowerment (SAVE) in 2003. Basic con-
cept of SAVE is to combine HIV prevention and AIDS care since
ANERELA+ believes that HIV prevention can never be effective with-
out caring and support for many AIDS cases [2,32,33].
Kurian [33] explained that S in SAVE includes the implementa-
tion of universal precaution procedures for health workers, sexual
abstinence, scientic-based intervention, safe practice of blood
transfusion, condom usage during intercourse, and using sterilized
syringe. A is referred to medical availability such as ARV medicine
for those who need it, treatment for opportunistic infections, and
sufcient supply of nutrition and clean water. V is referred to
voluntary and counseling testing, meanwhile E is referred to the
empowerment of community through education.
The education is in accordance to psychoeducation described by
Supratiknya [34] as psychological education or is also commonly
referred to as personality and social education. Psychoeducation
is a participatory learning that encourages students to reect on
their attitude and behavior [9,35]. Psychoeducation is proven to
be effective for health workers, including midwives, in improving
15
knowledge on HIV and AIDS so that it may reduce negative attitude
of midwives towards HIV and people with HIV, which then encour-
ages socialization on HIV and AIDS to patients of HMCP through
consultation [5,24,25,3641].
The result of interview between researcher and midwives and
physicians at PHC (September 2011; March 2012; July 2012), and
tracing of ofcial documents from Health Department and Pro-
fessional Organization showed that there have not been detailed
administrative procedure on what midwives and physician have to
do when they are dealing with HIV suspected patients. Midwives
knowledge on HIV and AIDS also has not had default standard. In the
curriculum of diploma program of Midwifery Studies, knowledge
on HIV and AIDS is only taught briey within the material concern-
ing Sexually Transmitted Diseases (STD) in Health Reproduction
course (2nd semester) and Midwifery Pathology (4th semester).
Therefore, it may be concluded that the issue studied in the research
was the fact that the quality service of midwives has not met the
maximum standards. It was due to midwives lack of knowledge
on HIV and AIDS, negative attitude towards HIV and AIDS, lack of
consultation skill, and lack of socialization about HIV and AIDS to
patients of HMCP.
The purpose of BIDAN CANTIK program was to improve the
service quality of midwives. The improvement was indicated
through improvement of knowledge on HIV and AIDS, reduction of
negative attitude on HIV and AIDS, caring consultation, and social-
ization on HIV and AIDS towards patients of HMCP. BIDAN CANTIK
program was an implementation of E (empowerment through
education) contained in SAVE approach. Meanwhile, materials in
BIDAN CANTIK program were an adaptation of S, A, and V.
2. Material and methods
2.1. Participants
Participants in the study were 12 midwives stationed at Pram-
banan PHC as experiment group and 12 midwives stationed at
Kalasan PHC as control group. Both PHC were in Sleman District and
were chosen using non randomized method since they had more
midwives than other PHC in Sleman. Inclusion criteria of partici-
pants were midwife who had graduated from Midwifery Program
and worked at PHC. Meanwhile, exclusion criteria of participants
were midwife who had patients, friends, or relatives who were
infected with HIV; was not studying at university for undergrad-
uate degree or higher; had not attended training or seminar about
HIV and AIDS within the last year.
2.2. Research instruments
2.2.1. Knowledge on HIV and AIDS test
The purpose of the test was to measure the level of knowledge
on HIV and AIDS of midwives, it was developed based on previous
studies [4,36,39,4244] containing aspects which were as followed:
general knowledge, causes, modes of transmission, symptoms of
HIV and AIDS, treatment and medicine. There were 40 items on the
test with Right or Wrong choices of answers. The result of try
out on 43 respondents showed reliability score of 0.92.
2.2.2. Negative attitude scale towards HIV
The purpose of the instrument was to reveal negative attitude
of midwives towards HIV and people living with HIV. There are 41
items with four alternative responses starting from very agree
to very disagree, and it was developed based on the previous
studies [42,45,46]. The scale was divided into three parts with
aspects: social isolation, discrimination, fairness, stigmatized mid-
wives, blaming, compelling to do VCT, and comfortable contact. The
result of try out on 43 respondents showed reliability score of 0.89.
16 A. Liem, M.G. Adiyanti / HIV & AIDS Review 12 (2013) 1422

2.2.3. Emphatic and caring consultation (ECC) observation sheet

ECC observation sheet was used to observe communication
between midwives and their patients in HMCP during consultation
[47] with indicators as followed: skill to pay attention to interlocu-
tor and basic listening skill.

2.2.4. Socialization on HIV and AIDS observation sheet

The purpose of the sheet was to observe the socialization pro-
cess, which was information delivery from midwives to patients
at HMCP during consultation which included: modes of transmis-
sion, general preventive measures, characteristics and symptoms of
HIV and AIDS, PMTCT of HIV, treatment and medicine, VCT of HIV.
Observers checked on the checklist of behavior, which contained
two responses: Not explained and Explained. It was developed
Fig. 1. Graphic of knowledge change on EGs participants.
based on the study conducted by Gamazina et al. [38].

b. Co-facilitator was an undergraduate or students of Master Pro-

2.2.5. Psychoeducation evaluation sheet gram of Psychology with experience of providing HIV and AIDS
It was used to evaluate the psychoeducation program given to psychoeducation.
midwives which included purpose, process, method, supporting c. Observer was an undergraduate or students of Master Program of
environment, facilitator, and content [47]. The model used was Psychology with experience of conducting observation on indi-
reaction evaluation, which included: whether participants liked the vidual and group.
program, whether participants felt that there were materials in the
program which were irrelevant to daily life or profession.
2.3. Analysis

2.2.6. Research design Data collected was analyzed quantitatively and qualitatively.
The study was an action research, which was a study to Statistical test was also performed using mixed design ANOVA [50]
solve targeted groups problem by taking advantage of collabora- and qualitative analysis was conducted in the form of narrative
tion between researcher and targeted group. Action research was description of the results of observation, interview, FGD, and par-
consisted of several stages [48] which were as followed: assess- ticipants response on evaluation sheets.
ment, diagnosis, designing intervention, intervention, quantitative
evaluation on the output, reection, and providing conclusion and 3. Results
suggestion as a repeated cycles.
The results were gained from one experiment group and one
control group. Each group was planned to consist of 12 midwives,
2.2.7. Intervention
however in the process there were only 10 midwives in each group.
Intervention used was quasi experimental method using non
One midwife in experiment group was on maternity leave and
random untreated control group design with dependent pretest
another midwife was still studying in higher Midwifery Program.
and posttest samples so that the effectiveness and designed alter-
Data gained from two midwives in control group was not used due
native model of intervention were able to be proven [49] (Table 1).
to the fact that their last education was lower than others midwives.
Intervention given was a form of HIV and AIDS psychoeducation
referred to as BIDAN CANTIK which included scope of materials as
followed: causes, modes of transmission, symptoms, prevention, 3.1. Quantitative analysis
HIV and AIDS care, HIV counseling, VCT, and active listening skill.
It was conducted for four meeting after service hours of midwives Based on Table 2 and Figs. 14, it might be concluded that the
at PHC, guided by a facilitator and co-facilitator, and was observed initial average scores of HIV knowledge of experiment and control
by observers with qualications as followed: groups were in medium category. After attending psychoeduca-
tion program, the average scores of HIV knowledge of experiment
group increased while the scores of control group remained the
a. Facilitator was a VCT counselor with more than ve years
experience, was working at health service line of work, have
experiences in providing HIV and AIDS psychoeducation for
health workers.

Table 1
Intervention design.

Group Pretest Treatment Posttest Follow-up

Experiment (EG) O1 X O2 O3
Control (CG) O1 O2 O3

Note. EG = midwives of Prambanan PHC; CG = midwives of Kalasan PHC; O1 = pretest:

knowledge on HIV and AIDS test, negative attitude scale towards HIV, ECC obser-
vation, and socialization on HIV and AIDS observation; O2 = pretest: knowledge on
HIV and AIDS test, negative attitude scale towards HIV, ECC observation, and social-
ization on HIV and AIDS observation; X = treatment BIDAN CANTIK; O3 = follow-up:
knowledge on HIV and AIDS test, negative attitude scale towards HIV, and FGD to
evaluate program. ECC observation, and socialization on HIV and AIDS observation
do not repeated to minimalized patients uncomfortable. Fig. 2. Graphic of knowledge change on CGs participants.
 A. Liem, M.G. Adiyanti / HIV & AIDS Review 12 (2013) 1422 17

Table 2
Brief description of HIV knowledge and negative attitude scores per group.

Experiment group Control group

Score TM EM Lv. SD Min Max Score TM EM Lv. SD Min Max

P1 20 26.1 Med 3.84 20 32 P1 20 23.3 Med 4.62 16 31

P2 20 31.9 High 3.45 25 37 P2 20 21.9 Med 4.01 16 29
P3 20 30.9 High 3.25 25 35 P3 20 22.3 Med 3.92 17 29
S1 102.5 115.5 Med 21.56 95 173 S1 102.5 121.6 Med 8.91 110 138
S2 102.5 103 Med 16.09 72 116 S2 102.5 119.4 Med 8.57 107 133
S3 102.5 103.1 Med 16.35 69 116 S3 102.5 119.6 Med 9.23 107 134

Note. P1 = Pretest score of knowledge; P2 = posttest score of knowledge; P3 = follow-up score of knowledge; S1 = pretest score of negative attitude towards HIV; S2 = posttest
score of negative attitude towards HIV; S3 = follow-up score of negative attitude towards HIV; TM = theoretical mean; EM = empirical mean; Lv. = level of empirical mean
(low knowledge < 14; medium knowledge = 1427; high knowledge > 27; low negative attitude < 83; medium negative attitude = 84123; high negative attitude > 123);
SD = standard deviation; Min = minimal score; Max = maximal score.

b. There was signicant difference between the average scores of

knowledge on HIV of experiment and control group (F = 19,176;
p < 0.0001).
c. There was signicant difference between the average scores
of knowledge on HIV and group types (F = 28,106; p < 0.0001).
The intervention which was in the form of BIDAN CANTIK psy-
choeducation program signicantly affect the improvement of
knowledge on HIV during posttest with effectiveness contribu-
tion as much as 61%.

T-test was performed to examine the difference found using

mixed ANOVA. It might be concluded that there was signicant
difference between the average scores during posttest and follow
Fig. 3. Graphic of negative attitude change on EGs participants.
up of experiment and control groups (t = 5979, p < 0.001; t = 5345,
p < 0.001). In the experiment group, there was signicant dif-
ference between the average scores during pretest and posttest
(t = 4949, p < 0.05) and during pretest and follow up (t = 4657;
p < 0.05). The fact that there was no signicant difference between
the average scores during posttest and follow up in the experi-
ment group showed that participants score improvement could
be maintained up until one week after psychoeducation program.
Meanwhile in the control group there was no signicant difference
between the average scores gained during pretest, posttest, and
follow up.
Furthermore, results of hypothesis test using mixed ANOVA for
negative attitude toward HIV are:

1. There was no signicant difference between the average scores

Fig. 4. Graphic of negative attitude change on CGs participants.
same. However, the average scores of negative attitude towards
HIV in both groups, both before and after the intervention, were in
medium category (did not change).
Pre-requirement test which included sphericity test and homo-
geneity test were performed before hypothesis testing using mixed
ANOVA. Result of sphericity test on HIV knowledge scores was
0.459 (p > 0.05) and on negative attitude towards HIV score was
0.073 (p > 0.05). Results of homogeneity test on HIV knowledge
scores before, after, and during follow up of psychoeducation were
0.435 (p > 0.05), 0.31 (p > 0.05), and 0.23 (p > 0.05). Results of homo-
geneity test on negative attitude towards HIV scores before, after,
and during follow up of psychoeducation were 1008 (p > 0.05), 5228
(p > 0.05), and 3686 (p > 0.05). The results showed that all data was
distributed normally and homogenously.
Furthermore, results of hypothesis test using mixed ANOVA for
HIV knowledge are:
a. There was signicant difference between the average scores
of knowledge on HIV during pretest and posttest (F = 1098;
p < 0.0001).
of negative attitude towards HIV during pretest and posttest
(F = 4203; p = 0.073).
2. There was signicant difference between the average scores of
negative attitude towards HIV of experiment group and control
group (F = 5298; p = 0.034).
3. There was no signicant interaction between the average scores
of negative attitude towards HIV and group types (F = 2085;
p = 0.139).
T-test was performed to examine the difference found using
mixed ANOVA with inter group variation source. It might be con-
cluded that there was signicant difference between the average
scores during posttest and follow up of experiment and con-
trol groups (t = 2689, p < 0.05; t = 2779, p < 0.05). However, the
decrease in the scores of negative attitude towards HIV of partici-
pants in the experiment group was not signicant when the t-test
was performed on the average scores during pretest and posttest
(t = 1652, p > 0.05).
The image of changes occurred on knowledge on HIV and nega-
tive attitude towards HIV in experiment and control groups during
pretest and posttest could be viewed in Figs. 5 and 6.
The result of observation on empathy of two midwives in exper-
iment group and two midwives in control group could be viewed
18 A. Liem, M.G. Adiyanti / HIV & AIDS Review 12 (2013) 1422
Fig. 5. Knowledge change. = EG;  = CG.
Fig. 6. Negative attitude change. = EG;  = CG.
in Figs. 7 and 8. The midwives participants in the experiment
group showed improvement of empathy during consultation with
patients of HMCP. However, the result of observation showed that
both groups did not show HIV socialization behavior to patients of
HMCP, both during pretest and posttest.
Fig. 7. Skill to pay attention (ECC) change.
Fig. 8. Basic listening skill (ECC) change.
3.2. Qualitative analysis
Qualitative analysis was performed on experiment group based
on the result of interview, FGD, observation of psychoeduca-
tion process, and observation on participants. Qualitative analysis
discussed psychological dynamic of individuals and groups. Partic-
ipants in the experiment group showed changes that stood out and
two midwives (Dw and Lz) observed during ECC showed meaning-
ful progress which then was discussed qualitatively.
The increase of HIV knowledge score was the most prominent
in midwife Ae. The increased knowledge aspects were the modes
of transmission and symptoms of HIV-AIDS. However, there were
no changes at all in HIV (negative) attitude score of midwife Ae.
According to midwife Ae, the purpose of the psychoeducation was
already clear, easy to understand, and easy to absorb. However, Ae
confessed that she was still confused on how to transfer the gained
information to the patients.
The decrease of HIV (negative) attitude score was the most
prominent in midwives En (62 points decrease), S (31 points
decrease), and Lz (23 points decrease). According to observation
result, those three midwives were active in taking notes, asking,
and answering questions given by the facilitator. According to mid-
wife En and S, the training materials were related to her daily job
and all of the materials were useful to them.
Before training I was very afraid with HIV or AIDS but after
this program I realized that things were not scary me anymore
because I know how HIV spreading deeper and more detail.
(Midwife En)
It turns out that compared to other diseases, HIV was not as
scary as I thought all this time. (Midwife S)
Midwife Dw experienced the increase of HIV knowledge score
by four points. However, the (negative) attitude score in midwife
Dw experienced an increase by 13 points and the follow up result
showed the score of 110. The increase of (negative) attitude score
in midwife Dw occurred in the inspection and treatment of the
HIV-infected patients. Midwife Dw agreed to place HIV-infected
patients in special hospitals and not mixing them with non-HIV
patients. However, during the interview it was revealed that mid-
wife Dw thought that it was necessary to be done in order to protect
the HIV-infected patients from viruses, bacterials, and germs that
could worsen the patients condition. Moreover, the HIV-infected
health workers were suggested not to handle the patients directly,
so they could avoid getting infected by their patients illness.
Midwife Lz experienced the increase of HIV knowledge score
by two points. The HIV (negative) attitude score of midwife Lz
was the lowest score in her group. Midwife Lz did not agree that
 A. Liem, M.G. Adiyanti / HIV & AIDS Review 12 (2013) 1422
HIV-infected patients have to be placed in special hospitals or
separated from non-HIV patients. According to midwife Lz, if it
happened, people would know which person was HIV-infected and
would give stigma to patients visiting HIV special hospitals.
If we do that then it would be known who are infected. People
would know and would put stigma on them [the HIV-infected
patients]. If that happen they wouldnt want to come again, and
those who have never come to the special hospital wouldnt
tell about their HIV-positive status so that they could still visit
regular hospitals. (Midwife Lz)
Generally, the participants felt that BIDAN CANTIK psychoedu-
cation was interesting, very useful, and related to their profession.
Even though this is not a new topic, we still need to understand
the ins and outs more deeply. (Midwife Lz)
All this time we only knew about HIV through brief informa-
tion. From this training, we got materials that were explained
more clearly, more understandably . . . From this training, we
knew about the wrong myths regarding HIV, how to prevent
infection, post-exposure treatment, and where to ask for help
in case of need. (Midwife Rw)
The participants felt that the general purpose of psychoedu-
cation was already clear because it was conveyed from the start
and according to them the purpose had been fullled. The per-
sonal purpose of the participants to understand HIV and AIDS more
deeply had also been fullled. However, they felt that more con-
crete actions need to be taken, such as VCT or psychoeducation for
villages. According to the participants, the psychoeducation process
was systematic and efcient enough. However, the participants
suggested that the psychoeducation should be done outside ofce
hours.
The methods used in the training, such as booklets, audio-
visual, power point presentation, sharing, discussion, illustration,
and role-play, could help the participants to understand the mate-
rials. Midwife Sm suggested to add more game methods to revive
participants spirit. Regarding the environment, the participants
felt uncomfortable with the rooms temperature, which was very
hot despite the presence of two fans in the room. The light, which
came from the window, and the circular positioning of the chairs
had been deemed comfortable by the participants.
Participants thought that the facilitator had a very good under-
standing of HIV and AIDS, could convey it clearly to the midwives,
and could keep a conducive class atmosphere. For the participants,
all of the materials were useful.
All of the materials were very useful because we cant learn
about HIV and AIDS piece by piece or per chapter. (Midwife Lz)
However, the most useful material according to the midwives
was the modes of transmission of HIV because before the training
they were very afraid of the infection. After knowing how HIV can
and cannot be transmitted their fear subsided. Moreover, the most
favorite material among the midwives was the topic of prevention
because it related to the transmission of HIV, even more because
of the nature of participants occupation as health workers which
has a high risk of HIV infection. Some of the participants did not
really like the material on ARV medicines because they thought it
was difcult to memorize the types and they felt that it was not
within their authority to assign medicines.
The evaluation from the facilitator was that the program would
be better implemented in a particular day and the midwives should
get assignment letter from the head of PHC. The purpose was to
ensure the midwives were in their top condition and could concen-
trate more on the program. Moreover, according to the facilitator,
it would be better if the head of PHC gave the opening speech of the
19
program so that the midwives could follow the whole process more
seriously. By giving the opening speech, the head of PHC would also
feel the responsibility in PMTCT of HIV. Regarding the room tem-
perature and the behaviors of several participants like being sleepy
or being busy with their cellular phones, facilitator argued that such
problems were challenges for the facilitator. They must be able to
maintain conducive learning atmosphere.
The observers reported that all participants seemed to be enthu-
siastic in following the program and some participants seemed to
more active compared to some others in asking and responding
to questions. The high temperature of the room made participants
and facilitator break into sweat, despite the presence of two electric
fans. During the process, a few participants seemed sleepy while
some seemed to be busy with their cellular phones. Seeing such
reactions, facilitator delivered the materials in a louder voice and
sometimes approached participants that seemed to be unfocused.
Facilitator seemed to master the materials given and could deliver
them systematically so that all materials were delivered well.
According to observational data, observers did not nd social-
ization of HIV and AIDS during the consultation process between
midwives and patients in HMCP, neither before nor after the
psychoeducation. From the interview result with observed mid-
wives and program evaluation of midwives in experimental group
through FGD, the reasons why the midwives did not give socializa-
tion of HIV and AIDS to HMCPs patients were revealed.
The midwives assessed that it was unnecessary to give social-
ization of HIV to HMCPs patients if they did not nd the symptoms
or medical history of patients that lead to HIV.
We have their medical history. If there were no signs or suspi-
cious things, I dont think its necessary to give them information
on HIV. If the patients came from the Panti, then we would give
that information. (Midwife Dw)
Dws last sentence asserted that the midwives tend to socialize
HIV to patients that were deemed high-risked. FGD result showed
that the midwives still believed the paradigm that good people
would not get HIV.
If we know the patients and their families are good people,
I dont think we need to give them information on HIV. It
feels rather weird to talk about HIV. Im afraid they would feel
insulted. (Midwife Rw)
On the other hand, the basic skill of listening and paying atten-
tion of the midwives in the experimental group experienced and
increase. However, that increase was not signicant compared to
the control group. A sub-aspect that has been mastered well was
talking with a tone that showed attention and care. Meanwhile the
sub-aspect that was still weak was paying attention to the patients
when they talked and giving encouraging statements.
Qualitatively, it can be concluded that BIDAN CANTIK psychoed-
ucation was useful for the midwives in improving their knowledge
on HIV and AIDS. However, the midwives still felt shy and confused
to channel their knowledge to HMCPs patients. The social-culture
norm also prevented the midwives from socializing HIV and AIDS
to HMCPs patients. This caused the absence of HIV and AIDS social-
ization behavior during observation.
4. Discussion
The research aimed to test the effectiveness of BIDAN CANTIK
psychoeducation in improving the public health centers midwives
service through knowledge/awareness on HIV, (negative) attitude
to HIV, socialization of HIV and AIDS, and the emphatic consultation
for the HMCPs patients. According to the presented result, BIDAN
CANTIK had signicantly observed in improving knowledge on HIV
20 A. Liem, M.G. Adiyanti / HIV & AIDS Review 12 (2013) 1422
and AIDS but not consistent in decreasing (negative) attitude of the
midwives toward HIV and AIDS. Observation result showed that
BIDAN CANTIK could not encourage the midwives to socialize HIV
and AIDS to HMCPs patients, as well as not signicantly proved to
be able to increase the midwives ECC.
This result is aligned with previous research [40] which found
that the knowledge of risk and risky behavior would not automat-
ically create behavioral changes in health workers. According to
Campbell et al. [51], the negative attitude of health workers toward
HIV could not be reduced only by giving information. Three rea-
sons why this could happen: (1) the health workers did not have
condence in their knowledge, even though that knowledge was
accurate; (2) they did not know how to take action based on the
possessed knowledge, in example:
I know enough about HIV and AIDS, but I have not been able to
take a lot of actions regarding HIV and AIDS. (Midwife Lz)
and (3) the growing stigma within the society discouraged them
in spreading information on HIV and AIDS. Moreover, in the villages
there was wrong myth or information on HIV and it had rooted
strongly, causing the health workers to work more strongly when
delivering accurate explanation on HIV and AIDS.
If we know the patients and their families are good people,
I do not think we need to give them information on HIV. It
feels rather weird to talk about HIV. I am afraid they would feel
insulted.
Negative attitude toward HIV was not only a cognitive process
that occurred to individual, but also a socio-cultural phenomenon
in community setting. That social phenomenon especially found in
developing countries in which the familial cultures are still held
rmly [52]. Several forming factors of stigma are cultural con-
struction and religious misunderstanding and they are present
in every community [53,54]. Kujiper [55] emphasized that atti-
tude and behavioral change need a long term process and strong
commitment. Religion and culture strongly affect the forming
of faith, life values, and individual as well as social behav-
ior. The result of Shaluhiyahs research [56] emphasized that
socio-cultural and socio-sexual factors affect teenagers sexual
behaviors.
Nyblade et al. [57] explained that midwives treating HIV-
infected patients also face similar stigma from the society. Even
if the midwife experienced exposure and then was contracted with
HIV, then she would blame herself and internalized the stigma.
Midwives and health workers were afraid to lose social status and
considered to be immoral if they were infected by HIV. That fear
was reected in midwife Sms story on several years worth of her
experience.
At that time there was a woman who was almost giving birth
and Sm was in charge in administration ofce. Several moments
later, Sm found out that the woman died and was declared as HIV
positive. Knowing that, Sm was really afraid that shed contract
the virus even though she had only done intake interview and
checked for blood pressure and she prayed that she would not
contract the virus. Sm did not do VCT since she did not know where
to go and whom to talk about it with. Even if she had known where
to do VCT, she would not have gone since she was not ready to nd
out about the result and people would alienate her.
The result above could be explained based on Planned Behavior
Theory [27], which is when a persons behavior can be predicted
from his/her behavior intention. Meanwhile, behavior intention
could be affected by attitude, subjective norm, and behavioral con-
trol, in which subjective norm and external behavior control are
socio-cultural constructed. Observation result showed that there
was no midwife who socialized HIV to patients at HMCP even when
negative attitude towards HIV had been decreased. Socialization
behavior did not show due to negative socio-cultural construction
towards HIV and AIDS.
The result was in accordance to the nding of Adekeye and
Adeusi [17] that had been described earlier, in which knowledge
and attitude altogether were only 5% affect the reduction of dis-
criminative behavior of health workers towards people living with
HIV. In the study, knowledge on HIV of participants in the control
group increased signicantly but their negative attitude did not
decrease signicantly. Meanwhile, changes in ECC occurred due to
the fact that the four midwives who were observed during ECC had
already had quite vast working experiences (more than 15 years
experiences) so that the skill to do ECC had been mastered well.
It implied to the small improvement of basic listening skill and
attentive skill of midwives participants in the experiment group.
On the other hand, quasi experiment with small number and
non randomized subject has a few limitations on validity [49].
First is statistical conclusion validity which is threated by extrane-
ous variance in the experimental setting, in example by rooms high
temperature and inaccurate effect size estimation with an example
is dichotomous HIV knowledges score making effect size become
underestimate. Second is internal validity threated by selection used
non randomized, history of subjects experience between meeting,
and maturation reected from age range from 22 years old until 54
years old. That differences are might be affected subjects cognition
when absorbing and memorizing information. Third is construct
validity threated by the weakness of check manipulation because
only used qualitative description from two observer. The last, exter-
nal validity threated by interaction of causal relationship with settings
because the possibility of social-cultural norm in rural area is dif-
ferent with urban area.
5. Conclusions
The results of this research showed that BIDAN CANTIK psychoe-
ducation could help improve the service of public health centers
midwives. The service of midwives was improved through the sig-
nicant increase of knowledge on HIV. However, BIDAN CANTIK was
not signicant in decreasing (negative) attitude toward HIV and
increasing ECC. BIDAN CANTIK also could not encourage the mid-
wives to socialize HIV and AIDS to HMC policlinics patients. This
happened because of social-culture factor such as: (1) the mid-
wives did not have condence in their knowledge, even though
that knowledge was accurate; (2) the midwives did not know how
to take action based on the possessed knowledge; (3) the growing
stigma within the society discouraged the midwives in spreading
information on HIV and AIDS. Moreover, as an alternative model
that had been newly implemented with small and non-randomized
subjects, the effectiveness of BIDAN CANTIK cannot be generalized
widely yet and has limitation on experiment validity.
6. Recommendations
6.1. For midwives of PHC
BIDAN CANTIK psychoeducation can be used to improve mid-
wives knowledge on HIV and AIDS but it is need to practice and
apply it to a daily basis so they can always remember the procedure.
BIDAN CANTIK can be used as an alternative procedure refer-
ence in dealing with HMCPs patients who are suspected to be
HIV-positive.
6.2. For psychologist
Psychologists can help midwives in showing less negative atti-
tude and increased empathy toward HIV orientation to them.
 A. Liem, M.G. Adiyanti / HIV & AIDS Review 12 (2013) 1422
6.3. For future researchers
a. BIDAN CANTIK psychoeducation can reduce midwives negative
attitude toward HIV and AIDS. However, for signicant decrease,
holding discussions with HIV-infected patients as well as HIV-
infected and HIV-exposed health workers can be tried.
b. The changes in knowledge and attitude alone are not enough
to push for HIV and AIDS socialization from PHC midwives to
HMC policlinics patients. It is necessary to add more materials
or special sessions to create follow-up action plan that they can
use with the involvement of the community or villagers.
c. To increasing internal validity is necessary to conduct random-
ized selection and smaller range of subjects age to avoid the
maturation.
d. To increasing construct validity is necessary to conduct quan-
titative manipulation check, in example presenting two raters
to scoring congruity between programs blue print and what
facilitator explain.
e. To increasing external validity is necessary to conduct this pro-
gram in various setting, in example between midwives of rural
PHC and urban PHC.
Conict of interest
None declared.
Financial disclosure
None declared.
Acknowledgements
Author (Andrian Liem) is grateful to Dr. M.G. Adiyanti, Psi., Prof.
Koentjoro, M.B.Sc., Ph.D., Psi., Rahmat Hidayat, M.Sc., Ph.D., Dr. Ira
Paramastri, Psi., Novan (PKBI DIY), Silmika Wijayanti, S.Psi., Yash-
inta Ardhiani P, S.Psi., Head of Puskesmas Prambanan, and Head of
Puskesmas Kalasan for the support in this research.
References
[1] S. Burke, I. Madan, Contamination incidents among doctors and midwives:
reasons for non-reporting and knowledge of risks, Occup. Med. 47 (8) (1997)
357360.
[2] J.R. Chinkonde, J. Sundby, F. Martinson, The prevention of mother-to-child HIV
transmission programme in Lilongwe, Malawi: Why do so many women drop
out, Reprod. Health Matt. 17 (33) (2009) 143151.
[3] F. Kasenga, Making it happen: prevention of mother to child transmis-
sion of HIV in rural Malawi, Global Health Action 3 (2010), http://dx.doi.
org/10.3408/gna.v310.1882.
[4] N.D. Labhardt, E. Manga, M. Ndam, J. Balo, A. Bischoff, B. Stoll, Early assessment
of the implementation of a national programme for the prevention of mother-
to-child transmission of HIV in Cameroon and the effects of staff training: a
survey in 70 rural health care facilities, Trop. Med. Int. Health 14 (3) (2009)
288293, http://dx.doi.org/10.1111/j.1365-3156.2009.02221.x.
[5] C.M. Ndikom, A. Onibokum, Knowledge and behaviour of nurse/midwives
in the prevention of vertical transmission of HIV in Owerri, Imo State,
Nigeria: a cross-sectional study, BMC Nurs. 6 (9) (2007), http://dx.doi.org/
10.1186/1472-6955-6-9.
[6] J.V. Lazarus, V. Rasch, J. Liljestrand, Midwifery at the crossroads in Estonia:
attitudes of midwives and other key stakeholders, Acta Obstet. Gynecol. Scand.
84 (2005) 339348.
[7] S.C. Leshabari, A. Blystad, M. Paoli, K.M. Moland, HIV and infant feeding coun-
selling: challenges faced by nurse-counsellors in northern Tanzania, Human
Resour. Health 5 (18) (2007), http://dx.doi.org/10.1186/1478-4491-5-18.
[8] P. Msellati, Improving mothers access to PMTCT programs in West
Africa: a public health perspective, Soc. Sci. Med. 69 (2009) 807812,
http://dx.doi.org/10.1016/j.socscimed.2009.05.034.
[9] H. Nordkvist, E. Pyykk, Knowledge, perceptions and attitudes among mid-
wifery students towards HIV/AIDS in Vietnam. A minor eld study report (Tidak
diterbitkan), Karolinska Institute, Swedia, 2008.
[10] WRATZ, White Ribbon Alliance, Tanzania Is It Worth it for Tanzania to Invest in
Community Midwives?. Debate Forum Report, White Ribbon Alliance for Safe
Motherhood in Tanzania, Tanzania, 2006.
21
[11] C.P.N. Kaponda, D.L. Jere, J.L. Chimango, A.F. Chimwaza, K.S. Crittenden, S.L.
Kachingwe, L.L. McCreary, J.L. Norr, K.F. Norr, Impacts of a peer-group inter-
vention on HIV-related knowledge, attitudes, and personal behaviors for Urban
Hospital Workers in Malawi, J. Assoc. Nurses AIDS Care 20 (3) (2009) 230242,
http://dx.doi.org/10.1016/j.jana.2008.12.005.
[12] AKBIDYO. (2009). AKBIDYO Latih Bidan Desa Soal HIV/AIDS. Retrieved from
http://kopertis5.org/index.php?p=detail berita&id=8685 on 18 January 2012.
[13] PAHO, Strengthening nursing and midwifery services for HIV/AIDS prevention
and control. Consensus document, Pan American Health Organization, USA,
2003.
[14] ICM, HIV and AIDS, position statement, International Confederation of Mid-
wives, Glasgow, 2008.
[15] WHO, Nursing role in HIV/AIDS care and prevention in South-east Asia region,
WHO Regional Ofce for South-east Asia, New Delhi, 2002.
[16] C. Bennet, A. Weale, HIV and AIDS awareness: an evaluation of a short training
programme for midwives, J. Adv. Nurs. 26 (1997) 273282.
[17] O.A. Adekeye, S.O. Adeusi, Attribution patterns, attitude and knowledge of
HIV/AIDS on sexual behavioural change among students of Covenant Univer-
sity, OTA, Nigeria, Ife Psychologia 19 (1) (2011) 255269.
[18] Y. Li, C.S. Scott, L. Li, Chinese nursing students HIV/AIDS knowledges,
attitudes, and practice intentions, Appl. Nurs. Res. 21 (2008) 147152,
http://dx.doi.org/10.1016/j.arnur.2006.10.004.
[19] A. Sohn, S. Park, HIV/AIDS knowledge, stigmatizing attitudes, and related
behaviors and factors that affect stigmatizing attitudes against HIV/AIDS
among Korean adolescents, Public Health Res. Respect. 17 (2012),
http://dx.doi.org/10.1016/j.phrp.2012.01.004.
[20] J.W. Yiu, W.W.S. Mak, W.S. Ho, Y.Y. Chui, Effectiveness of a knowledge-contact
program in improving nursing students attitudes and emotional competence
in serving people living with HIV/AIDS, Social Sci. Med. 71 (2010) 3844,
http://dx.doi.org/10.1016/j.soscimed.2010.02.045.
[21] J. Lou, S. Chen, Relationship among sexual knowledge, sexual attitudes, and
safe sex behaviour among adolscents: a structural equation model, Int. J. Nurs.
Stud. 46 (2009) 15951603, http://dx.doi.org/10.1016/j.ijnurstu.2009.05.017.
[22] M. Askarian, R. Shiraly, K. Aramesh, M. McLaws, Knowledge, attitude, and prac-
tices regarding contact precautions among Iranian physicians, Infect. Control
Hosp. Epidemiol. 27 (8) (2006) 868872.
[23] L.R. Norman, R. Carr, J. Jimnez, Sexual stigma and sympathy: attitudes toward
person living with HIV in Jamaica, Cult. Health Sexual. 8 (5) (2006) 423433,
http://dx.doi.org/10.1080/13691050600.
[24] M. Simbar, M. Shayan-Menesh, F. Nahidi, A. Akbar-Zadeh, Health belief of
midwives about HIV/AIDS protection and the barriers to reducing risk of
infection: an Iranian study, Leadersh. Health Serv. 24 (2) (2011) 106117,
http://dx.doi.org/10/1108/17511.87111112894.
[25] W.R. Wolfe, S.D. Weiser, K. Leiter, W.T. Steward, F.P. Korte, N. Phaladze, V.
Iacopino, M. Heiser, The impact of universal access to antiretroviral therapy
on HIV stigma in Botswana, Am. J. Public Health 98 (10) (2008) 18651871.
[26] A.R. Baron, D. Byrne, Psikologi Sosial. Jilid I, Erlangga, Jakarta, 2003.
[27] M. Fishbein, I. Ajzen, Belief, Attitude, Intention, and Behavior: An Introduction
to Theory and Research, Addison-Wesley, Philippines, 1975.
[28] C. Antonia, Kerry.C. Lyons, Health Psychology: a Critical Introduction,
Cambridge University, United Kingdom, 2006.
[29] Harian Bhirawa. (2011). Bersinggungan Langsung, Bidan Rawan Tertu-
lar HIV/AIDS. Retrieved from http://www.harianbhirawa.co.id/publik/32443-
bersinggungan-langsung-bidan-rawan-tertular-hivaids on 18 January 2012.
[30] T. Mathole, G. Lindmark, B.M. Ahiberg, Knowing but not knowing: providing
maternity care in the context of HIV/AIDS in rural Zimbabwe, Afr. J. AIDS Res.
5 (2) (2006) 133139.
[31] M. Mondiwa, Y. Ilauck, Malawian midwives perceptions of occupational risk
for HIV infection, Health Care Women Int. 28 (2007) 209223, http://dx.doi.org/
10.1080/07399330601179778.
[32] C.M. Audet, J. Burlison, T.D. Moon, M. Sidat, A.E. Vergara, S.H. Vermund,
Sociocultural and epidemiological aspects of HIV/AIDS in Mozambique, BMC
Int. Health Human Rights 10 (15) (2010), http://dx.doi.org/10.1186/1472-
698x-10-15.
[33] M. Kurian, ABC, AV or SAVE, Contact 182 (2006) 68.
[34] A. Supratiknya, Psikoedukasi: Merancang Program dan Modul (edisi revisi),
Universitas Sanata Dharma, Yogyakarta, 2011.
[35] UNAIDS, Reducing HIV stigma and discrimination: a critical part of National
AIDS Programmes, Joint United Nations Programme on HIV/AIDS, Genewa,
2007.
[36] A. Ajuwon, F. Funmilayo, O. Oladepo, K. Osungbade, M. Asuzu, Effects of
training programme on HIV/AIDS prevention among Primary Health Care
Workers in Oyo State, Nigeria, Health Educ. 108 (6) (2008) 463474,
http://dx.doi.org/10.1108/09654280810910872.
[37] J. Busza, Challenging HIV-Related Stigma and Discrimination in Southeast Asia:
Past Successes and Future Priorities. Literature Review, The Population Council,
USA, 1999.
[38] K. Gamazina, I. Mogilevkina, Z. Parkhomenko, A. Bishop, P.S. Coffey, T. Brazg,
Improving quality of prevention of mother-to child-HIV transmission ser-
vices in Ukraine: a focus on provider communication skills and linkages to
community-based non-govermental organizations, Cent. Eur. J. Public Health
17 (1) (2009) 2024.
[39] Y. Sasaki, M. Ali, Sathiarany, K. Kanal, K. Kakimoto, Prevalence and barriers to
HIV testing among mothers at a Tertiary Care Hospital in Phnom Penh, Cam-
bodia: barriers to HIV testing in Phnom Penh, Cambodia, BMC Public Health 10
(494) (2010), http://dx.doi.org/10.1186/1471-2458-10-494.
22 A. Liem, M.G. Adiyanti / HIV & AIDS Review 12 (2013) 1422
[40] D.B. Somma, C.K. Bodiang, S. Mollet, L. Ruedin, The Cultural Approach to
HIV/AIDS Prevention, Swiss Agency for Development and Cooperation, Swiss,
2003.
[41] UNAIDS, HIV-Related Stigma, Discrimination, and Human Rights Violations:
Case Studies of Successful Programmes, Joint United Nations Programme on
HIV/AIDS, Genewa, 2005.
[42] A. Andrewin, L. Chien, Stigmatization of patients with HIV/AIDS among doc-
tors and nurses in Belize, Aids Patient Care STDS 22 (11) (2008) 897905,
http://dx.doi.org/10.1089/apc.2007.0219.
[43] M. Kermode, W. Holmes, B. Langkham, M.S. Thomas, S. Gifford, HIV-related
knowledge, attitudes and risk perception amongst nurses, doctors, and
other healthcare workers in Rural India, Indian J. Med. Res. 122 (2005)
258264.
[44] D. Wijayanto, Makalah Keperawatan Anak tentang Ibu Hamil dengan HIV/AIDS,
STIKES Bahrul Ulum, Batu, 2011.
[45] B.L. Genberg, S. Kawichai, A. Chingono, M. Sendah, S. Chariyalertsak, K.A.
Konda, D.D. Celentano, Assessing HIV/AIDS stigma and discrimination in
developing countries, AIDS Behav. 12 (2008) 772780, http://dx.doi.org/
10.1007/s10461-007-9340-6.
[46] L.R. Uys, W.L. Holzemer, M.L. Chirwa, P.S. Dlamini, M. Greeff, T.W. Kohi,
L.N. Makoae, A.L. Stewart, J. Mullan, R.D. Phethu, D.H. Wantland, K.L.
Durrheim, Y.P. Cuca, J.R. Naidoo, The development and validation of the
HIV/AIDS stigma instrument-nurse (HASI-N), AIDS Care 21 (2) (2009) 150159,
http://dx.doi.org/10.1080/09540120801982889.
[47] Ardhiani, L.N. (2009). Keterampilan Bidan dalam Berkomunikasi dan Mende-
teksi Permasalahan Psikologis Pasien di Puskesmas. Thesis (unpublished).
Yogyakarta Fakultas Psikologi Universitas Gadjah Mada.
[48] M. Nazir, Metode Penelitian, Ghalia, Bogor, 2005.
[49] W.R. Shadish, T.D. Cook, D.T. Campbell, Experimental and Quasi-Experimental
Designs for Generalized Causal Inference, Houghton Mifin, New York, 2002.
[50] A. Field, Discovering Statistics Using SPSS, Sage Publications, London, 2005.
[51] C. Campbell, Y. Nair, S. Maimane, Z. Sibiya, Understanding and challenging
HIV/AIDS stigma, Centre for HIV/AIDS Networking, Durban, 2005.
[52] A.P. Mahajan, J.N. Sayles, V.A. Patel, R.H. Remien, S.R. Sawires, D.J. Ortiz, G.
Szekeres, T.J. Coates, Stigma in the HIV/AIDS epidemic: a review of the literature
and recommendations for the way forward, AIDS 22. (Suppl. 2) (2008).
[53] L. Liu, Interpersonal relationships and HIV/AIDS stigma in China, Interpersona
4 (Suppl. 1) (2010) 7592.
[54] N.C. Mbonu, B. Borne, N.K.D. Vries, Stigma of people with HIV/AIDS in
Sub-Saharan Africa: a literature review, J. Trop. Med. (2009) 145891,
http://dx.doi.org/10.1155/2009/145891.
[55] P. Kujiper, Religion and HIV/AIDS: dening issues of our time, UNAIDS, 2006.
[56] Z. Shaluhiyah, Socio-cultural and socio-sexual factors inuence the premari-
tal sexual behaviour of Javanese youth in the era of HIV/AIDS, Jurnal Promosi
Kesehatan Indonesia 2 (2) (2007) 6172.
[57] L. Nyblade, A. Stangl, E. Weiss, K. Ashburn, Combating HIV stigma in health
care settings: what works? J. Int. AIDS Soc. 12 (15) (2009), http://dx.doi.org/
10.1186/1758-2652-12-15.