The incidence of the human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) continues to escalate in the United States (U.S). The prevalence of HIV/AIDS is especially high in the South, particularly amongst African American males who have sex with other males [1]. Currently, in the state of Mississippi, HIV/AIDS is a major healthcare concern that is often misunderstood; hence, more than often unaddressed. The misunderstanding is related to the stigma attached to the disease. According to the Centers for Disease Control (CDC, 2017), the stigma toward HIV/AIDS is a major problem in the U.S. The stigma has been linked to the increasing complexities of HIV/AIDS treatment and management. Addressing the stigma associated with HIV/AIDs is key to reversing the trajectory of the management of the disease in the U.S. healthcare system [1].

According to the Mississippi State Department of Health (2016), higher rates of HIV/AIDS in Mississippi typically occur in rural, low socioeconomic areas of the state. Mississippi has the highest rates of individuals living below the poverty line. Individuals with a low socioeconomic status often have limited access to healthcare. Further, Federally Qualified Health Centers (FQHCs) in Mississippi offer limited HIV/AIDS testing and treatment services. These factors contribute to the prevalence of HIV/AIDS in the state [2].            

Stigma remains an issue that is continuing to be detrimental to the health of those living with HIV/AIDS. Hatzenbuehler, Phelan, and Link noted that HIV/AIDS stigma can greatly affect whether an individual will choose to be tested, disclose an affirmative diagnosis, and adhere to medication instructions. Therefore, stigma can alter an individual’s day-to-day activities and quality of life. Not only does stigma affect individuals with HIV/AIDS, but it can also affect the quality of life of nurses who care for those with HIV/AIDS. Many people perceive nurses as being “contagious” since they are in close contact with HIV/AIDS patients [3].

The purpose of this study was to examine rural, community-based nurses’ perceptions related to HIV/AIDS stigma while caring for patients with the disease in rural areas of Mississippi. This study further assessed nurses’ perceptions of whether they stigmatize patients living with HIV/AIDS and whether nurses are stigmatized by family members for providing care to patients living with HIV/AIDS.

The following databases were utilized in this widespread literature search: Network Digital Literary, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PubMed, and OCLC First Search. The keywords used for the search were HIV/AIDS in ‘African Americans’, ‘stigma’, ‘Neuman systems model’, ‘HIV/AIDS’, ‘rural’, and ‘HIV/AIDS nursing care’. The literature search yielded systematic reviews, dissertations, literature reviews, policy briefs, and a plethora of research studies between the years of 2001 through 2019.

Research questions and hypotheses

Research questions: This mixed-methods study was designed to address the following four research questions:

• Do nurses in rural Mississippi, who care for individuals with HIV/AIDS perceive they are stigmatized by family members for providing care to patients living with HIV/AIDS?
• What are the perceptions of rural, community-based nurses regarding the stigma associated with HIV/AIDS?
• What are the perceived factors that contribute to stigma exhibited by nurses in rural Mississippi who care for individuals with HIV/AIDS?
• Are nurses’ demographic characteristics correlated with the presence or lack of perceived stigma when caring for patients living with HIV/AIDS?

Hypotheses: The quantitative section of this mixed-methods study tested the following three hypotheses:

H₁: An individual’s educational level is related to his or her presence of stigmatizing behavior.

H₂: Age is directly related to one’s presence of stigmatizing behavior.

H₃: Gender is related to one’s presence of stigmatizing behavior.            

Sample/Setting

The target population for this study was nurses who were employed at Mississippi’s Federally Qualified Health Centers (FQHCs) that care for patients with HIV/AIDS. The researcher gained access to the FQHC population by contacting the Mississippi Primary Health Care Association (MPHCA). The MPHCA is the membership organization of the 21 FQHCs in the state of Mississippi. Federally Qualified Health Centers were used because they provide the majority of care to the poor and underserved in the state of Mississippi. Those living with HIV/AIDS in Mississippi overwhelmingly from lower socioeconomic communities in the state. According to the Bureau of Primary Healthcare (2017), FQHCs are a valuable safety net in communities for the poor and underserved patients living with various chronic diseases such as HIV/AIDS [4].

The researcher used a convenience sampling technique. ‘A convenience sample’ is a type of non-probability sampling method where the sample is taken from a group of people easy to contact or to reach [5]. An advantage of convenience sampling is that its subjects are easy to access and easy to measure [5]. A limitation of this technique is that the subjects have the potential to be biased since they can choose to respond to the survey questions or not [5]. The sample size was determined by power analysis and recommended a representative sample size of 40 participants. The power analysis generated a 95% confidence interval using a two-tailed non-directional hypothesis.

This study was guided by the following inclusion criteria: (a) the participant must be a nurse (Registered Nurse, Licensed Practical Nurse, or Nurse Practitioner), (b) able to read and write English, (c) work in a Federally Qualified Health Center, and (d) provide care to patients with HIV/AIDS. A recruitment flyer that included details about the study and the researcher’s contact information was circulated throughout the FQHCs to petition participants.

Ethical and human subject protection: Participation in this study was voluntary. Therefore, each participant had the right to self-determination. Approval to conduct the study was obtained from the Institutional Review Board (IRB) at Hampton University. The ethical principle of autonomy was respected by allowing the participants to withdraw from the study at any time.

Instrumentation

Demographic questionnaire: Each participant completed a researcher-developed 11-item fill-in-the blank demographics questionnaire. The questionnaire asked the county/city of residence, county/city of practice, name of health center/clinic, age, gender, race, number of years as a nurse, number of years caring for clients with HIV/AIDS, educational level, trainings/certifications, and the approximate number of HIV/AIDS patients cared for as a nurse.  A random participant number was placed on the demographic questionnaire form; however, no identifying information was used.       

HIV/AIDS stigma instrument-nurse (HASI-N): Dr. William Holzemer developed the HIV/AIDS Stigma Instrument-Nurse. The development of this tool was based upon literature that indicated that the HIV/AIDS stigma could greatly affect the quality of life for individuals living with HIV/AIDS, access to care, delays in treatment, and the job satisfaction and performance of nurses [6]. Dr. Holzemer granted permission for the HASI-N survey to be used in this study.

The HASI-N is a survey with a Cronbach’s alpha of 0.90. The HASI-N contains 19 items on a 4-point Likert-type scale: 1 = never, 2 = once or twice, 3 = several times, 4 = most of the time. The instrument is comprised of two subscales. The first subscale (items 1–10) measures whether the participants perceive that nurses stigmatize patients living with HIV/AIDS [6]. The second subscale (items 11–19) measures whether the participants perceive they are stigmatized for providing care to patients living with HIV/AIDS [6].

The internal consistency or reliability of conceptually related quantitative survey item was evaluated with Cronbach’s alpha [7]. Cronbach’s alpha is used when the survey includes conceptually-related statements measured on a Likert-scaled or dichotomously scored array of responses and was administrated only once. Cronbach’s alpha is a standard test of internal consistency. According to Gilner and Morgan (2000), a Cronbach’s alpha of .70 or higher is ideal for reliability.

Data collection procedures

After gaining approval from the Hampton University IRB, potential participants were contacted via telephone or in-person using information obtained from the Mississippi Primary Health Care Association. The participants received a packed that included an informed consent form, a participant information sheet, and instructional materials. The information sheet provided details pertaining to the purpose of the study, research locations, and assurance that participants’ responses would remain anonymous. The participant information sheet also included an invitation to participate in the study, confidentiality, and the investigator’s contact information. Participants received a full explanation of the study procedures. All participants were required to return the consent form to the investigator via email or by postal service. Informed consent was required from each participant prior to the commencement of the study. Participants were informed that they could refuse to be included in the study at any time without being penalized.

After reviewing the information sheet, participants were asked to do the following:

• Complete a quantitative instrument tool (HASI-N)
• Complete a demographic questionnaire form

Quantitative data analysis

Data obtained from the HASI-N survey and the demographic questionnaires were analyzed using the latest version of Statistical Package for the Social Sciences (SPSS v. 25). Independent Sample t tests were run to identify categorical variables (e.g. age, education, and county of residency).  Because this study employs a correlation design, Pearson correlation was utilized. According to Cohen (1988), Pearson correlation is essential to evaluating linear relationships between two continuous variables (presence of stigma or perceived stigma). When a change in one variable is associated with a proportional change in another variable, the relationship is considered linear [8]. Once data for the study was collected, the researcher created a data set and uploaded it to SPSS for analysis.

Demographics

The researcher utilized a convenience sampling technique that yielded a sample of forty-seven nurses (n = 47). Demographic data were collected by a researcher-developed demographic questionnaire. Thirty-eight females (n = 38), and nine males (n = 9) were included in the study. Forty-six participants (n = 46) were African Americans. The remaining participant (n = 1) was Native American. There were no Caucasian nurses included in the sample. Fifteen (32%) nurses held a Master of Science in Nursing (MSN) degree. Thirteen (28%) were Licensed Practical Nurses (LPNs). Seven (15%) nurses held a Bachelor’s of Science in Nursing (BSN) degree. Three (6%) nurses held non-BSN degrees. Four (8%) nurses held doctoral degrees. It was assumed by the researcher that all nurses provided honest responses.  Figure 1 illustrates the distribution of nurses by degrees, which are listed in ascending order with the doctorate degree as the highest educational level.

Figure 1: Frequency distribution of the numbers of nurses per educational category.

The average nurse age was 40 years old. However, the age range was a broad span of four decades, range = 42 years; the youngest nurse was 23 years old, whereas the oldest nurse was 65 years old. The nurses had been working an average of 16 years as a nurse, and an average of 11 years as a HIV/AIDS nurse. Nurses were also asked to estimate the total number of HIV/AIDS patients for whom they had cared. The column on Table 1, labeled Number of HIV/AIDS patients^, shows that the nurses estimated having worked with an average of 45 HIV/AIDS patients across their careers. The confidence interval estimated that the true number of HIV/AIDS patients was between 30 and 60. Table 1 shows the descriptive statistics for age and professional nursing experience.

Note: 95% CI = 95% confidence interval of the mean. LB = lower bound of the 95% CI. UB = upper bound of the 95% CI. Number of HIV/AIDS Patients = Estimated Number of HIV/AIDS patients cared for to this point. IQR = Interquartile range. Skew SE = 0.35. Kurtosis SE = 0.69

Table 1: Descriptive Statistics for Age and Professional Experience.

		Age	Years as a Nurse	Years as HIV/AIDS Nurse	Number of HIV/AIDS Patients
M (SE)		40.61       (1.35)	15.70 (1.48)	10.98 (1.19)	45.00 (7.15)
95% CI	LB	37.87	12.71	8.58	30.58
	UB	43.34	18.68	13.38	59.42
Median		39.00	13.00	10.50	25.00
Variance		84.77	101.28	65.44	2302.50
SD		9.20	10.06	8.09	47.98
Minimum		23	1	1	2
Maximum		65	46	35	200
Range		42	45	34	198
IQR		11	11	13	50
Skewness		0.51	1.07	0.83	1.56
Kurtosis		0.35	1.24	0.50	2.11

Nurses were asked to report any trainings or certifications they had obtained that focused on the care of individuals with HIV/AIDS. Of the 47 nurses, 39 (83%) had not obtained additional HIV/AIDS training. In contrast, 8 nurses (17%) had obtained additional HIV/AIDS training. Table 2 provides a listing of specialized training of nurses in the care of HIV/AIDS patients.

Table 2: Specialized Training or Certification in the Care of HIV/AIDS Patients.

Nurse	Training or Certification
Nurse 3	PEP PREP - MS State Department of Health
Nurse 6	Conferences on the care of HIV/AIDS patients, prep medication, treatment, and follow up
Nurse 14	Understanding the HIV Epidemic, providing quality of care for the at-risk client and those living with HIV
Nurse 16	Medication (HIV Meds)
Nurse 30	Board of Nursing Required
Nurse 35	Class in Jackson, MS
Nurse 43	Testing & Counseling
Nurse 49	AAHIVM (American Academy of HIV Medicine)

Study results

Data obtained from the HASI-N survey and the demographic questionnaires were analyzed using the latest version of Statistical Package for the Social Sciences (SPSS v. 25) to answer the research questions of the study.

Research question one:  Do nurses in rural Mississippi who care for individuals living with HIV/AIDS perceive they are stigmatized by family members for providing care to patients living with HIV/AIDS? HASI-N survey item 17 asked nurses to estimate the frequency with which their spouse feared that the nurse would bring the HIV virus home from work and infect them. Nine out of ten nurses said they never felt stigmatized by their spouses in this way or felt stigmatized like this once or twice. Thirty-three (70%) nurses said their spouse never feared contagion. Nine (20%) nurses said their spouses feared contagion once or twice. These two responses accounted for 42 out of the 47 nurses for a cumulative total of 90% of the nurses. The five remaining nurses were divided: four (8%) nurses said their spouses feared contagion several times. One (2%) nurse said that her husband feared contagion most of the time.

Figure 2: Frequency distribution of responses to nurse’s spouse fearing HIV/AIDS contagion from the HIV/AIDS nurse.

Figure 2 shows the percentages of nurses by their responses about spousal attitudes towards possible contagion.

There were nine items on the HASI-N survey, including item 17, that measured the stigma that nurses receive from anyone (items #11-19). This section highlights the result of analyzing all of these items together. Internal consistency was good, Cronbach’s alpha = .93. Therefore, a single overall summated scale was generated as the mean value of these nine responses for each nurse. This overall scale was labeled Stigma against Nurses. Its range of possible values was 1-4, the same as the Likert scale upon which it was based.

The boxplot of the overall scale Stigma against Nurses variable is shown in Figure 3 and illustrates that the bulk of the data points fell at the low end of the scale. Specifically, the box’s location at the bottom of the graph across from the lowest values, squat height, and value of the top whisker at only 1.5 on a 4-point scale together indicated the construction of the schematic diagram. The visualization shows why data points with values of 2 or more emerged as extreme cases (recall that 2 = once or twice, and the scale topped out at 4 = most of the time). Forty-one (87%) nurses never felt stigmatized by other people for their work with HIV/AIDS patients. Six nurses (13%) emerged as extremes. For those six nurses, four said they experienced stigma once or twice. Nurse 44 felt stigmatized several times. The most extreme nurse was Nurse 16, who had worked only 2 years as an HIV/AIDS nurse out of their 30 years as a nurse, felt stigmatized most of the time. Nurse 16 indicated that their spouse feared contagion from them ‘most of the time. The subscales were compared to the overall scale to see if the overall Stigma against Nurses scale was clearly characterized by either one of the subscales or represented both types of stigmatizing behavior.

Figure 3: Boxplot of the Stigma against nurses.

One subscale was derived from five of the nine HASI-N survey items (11, 12, 13, 14, and 18) that measured condemnation in the form of accusing or gossiping that HIV/AIDS nurses had the HIV/AIDS disease, caught the disease from their patients, and/or spread the disease. A sample item for this subscale was “People said nurses would only work with HIV/AIDS patients if they had AIDS themselves.” The internal consistency was good with a Cronbach’s alpha = .87 for all five subscales. A mean value of these five responses was generated for each nurse and labeled as a subscale, HIV Nurses Have HIV.

The other subscale was derived from two of the nine HASI-N survey items (15, 19) that measured stigma as the amount of name-calling. A sample item was “Someone called a nurse names because he/she takes care of HIV/AIDS patients.” The internal consistency was good with a Cronbach’s alpha = .76. The mean value of these two responses was generated for each nurse and labeled as a subscale, HIV Nurses Called Names.

The three means were very close in value. Recalling that the survey scale was 1 = never, 2 = once or twice, 3 = several times, and 4 = most of the time, all three means translated into ‘never’ experiencing stigma. The similarity of means indicated that the overall Stigma against Nurses scale was about equally comprised of accusations of having or spreading the disease and being called names. Additionally, correlations were checked and verified this impression. The correlation between Stigma against Nurses and HIV Nurses Have HIV, was positive, strong, and significant, r (44) = .95, p < .001, r² = 90%. The correlation between Stigma against Nurses and HIV Nurses Called Names, was also positive, strong, and significant, r (44) = .83, p < .001, r² = 69%. The descriptive statistics for the overall Stigma against Nurses variable and the two subscales (HIV Nurses Have HIV; HIV Nurses Called Names) are listed in Table 3.

Table 3: Descriptive Statistics for the Stigma Expressed against HIV/AIDS Nurses.

		Stigma against Nurses	HIV Nurses Have HIV	HIV Nurses Called Names
Mean (SE)		1.32 (0.07)	1.28 (0.07)	1.38 (0.08)
95% CI	LB	1.17	1.13	1.21
	UB	1.48	1.44	1.55
Median		1.11	1.20	1.00
Variance		0.27	0.26	0.33
SD		0.52	0.51	0.58
Minimum		1.00	1.00	1.00
Maximum		3.78	3.60	4.00
Range		2.78	2.60	3.00
IQR		0.33	0.20	0.50
Skewness		2.81	2.83	2.37
Kurtosis		9.76	8.98	7.86

Note: 95% CI = 95% confidence interval of the mean. LB = lower bound of the 95% CI. UB = upper bound of the 95% CI. IQR = Interquartile range. Skew SE = 0.34.Kurtosis SE = 0.68.

Research question two: What are the perceptions of rural, community-based nurses regarding the stigma associated with HIV/AIDS? Evidence presented for Research Question one argued that nurses experience little or no stigma associated with their work as HIV/AIDS nurses. Only one nurse out of the 47 expressed any personal interest in their HIV/AIDS patients. Nurse 23 admitted being intensely curious about their patient’s story. Overall, nurses were wholly professional and impersonal. 

Research question three: What are the perceived factors that contribute to stigma exhibited by nurses in rural Mississippi who care for individuals with HIV/AIDS? This section presents quantitative measures of the extent to which nurses who participated in this research observed other nurses stigmatizing HIV/AIDS patients. Next it shows the results of exploring factors that could contribute to nurse-based stigma. This question was also addressed with qualitative data, presented in a separate subsection.

Items (1-10) in the HASI-N survey asked nurses to rate how often they observed other nurses exhibit stigma toward HIV/AIDS patients in their care. The 10 items had good internal consistency, with a Cronbach’s alpha = .93. The mean value of these 10 responses was generated for each nurse as the overall scale and labeled, Nurses Stigmatize HIV Patients.

The overall scale, Nurses Stigmatize HIV Patients, had five subscales that were also derived and compared to the overall scale. One subscale was derived from the three survey items (1, 6, 9) that measured instances of nurses neglecting HIV patients. A sample item was “A nurse provided poorer quality care to an HIV/AIDS patient than to other patients.” The internal consistency was good with a Cronbach’s alpha = .87. The mean value of these three responses was generated for each nurse and labeled as a subscale, Nurse Neglect.

A second subscale was derived from the three survey items (4, 5, 7) that measured instances of nurses ignoring the needs of HIV patients. A sample item was “A nurse ignored the physical pain of an HIV/AIDS patient.” The internal consistency was good with a Cronbach’s alpha = .85. The mean value of these three responses was generated for each nurse and labeled as a subscale, Nurse Negating.

A third subscale was derived from the two survey items (3, 8) that measured nurses who were afraid to catch the disease from the patient. A sample item was, “A nurse made a HIV/AIDS patient do things for himself/herself to avoid touching him/her.” The internal consistency was good with a Cronbach’s alpha = .82. The mean value of these two responses was generated for each nurse and labeled as a subscale, Nurse Fear Contagion.

The fourth and fifth subscales were each comprised of one survey item. Verbal abuse from a nurse to a patient was survey item 2. The item stated, “A nurse shouted at or scolded an HIV/AIDS patient”. Avoidance of a patient from a nurse was survey item 10, which stated, “Nurses made HIV/AIDS patients wait for care”. Because these were both single items, Cronbach’s alpha statistics were not applicable.

The means were very close in value. Given the survey Likert scale (1 = never, 2 = once or twice, 3 = several times, 4 = most of the time), all of these means translated into frequencies between ‘never’ and ‘once or twice.’ That is, nurse participants in this study never observed other nurses exhibiting stigma towards HIV patients or observed it once or twice. Recall the nurses represented an average of 16 years of experience as a nurse. In addition, the similarity of means indicates that the overall Nurses Stigmatize HIV Patients variable was about equally comprised of neglect, negating, fearing contagion, avoiding, and verbally abusing patients. The descriptive statistics for the stigma expressed by HIV/AIDS nurses variable (Stigmatize) and the subscales (Neglect, Negate, Fear Contagion, Avoid, and Verbal Abuse) are listed on Table 4.

Note: 95% CI = 95% confidence interval of the mean. LB = lower bound of the 95% CI. UB = upper bound of the 95% CI. IQR = Interquartile range. Skew SE = 0.34. Kurtosis SE = 0.68. Nurses Stigmatize = Nurses Stigmatize HIV Patients.

Research question four: Are nurses’ demographic characteristics correlated with the presence or lack of perceived stigma when caring for patients living with HIV/AIDS?

Table 4: Descriptive Statistics for Stigma Expressed by HIV/AIDS Nurses.

		Stigmatize	Neglect	Negate	Fear Contagion	Avoid	Verbal Abuse
Mean (SE)		1.40 (0.09)	1.37 (0.09)	1.34 (0.09)	1.60 (0.12)	1.46 (0.11)	1.24 (0.09)
95% CI	LB	1.22	1.19	1.15	1.36	1.22	1.06
	UB	1.58	1.55	1.52	1.84	1.69	1.42
Median		1.10	1.00	1.00	1.00	1.00	1.00
Variance		0.38	0.38	0.37	0.66	0.61	0.36
SD		0.61	0.62	0.61	0.81	0.78	0.60
Minimum		1.00	1.00	1.00	1.00	1	1
Maximum		3.80	4.00	4.00	3.50	4	4
Range		2.80	3.00	3.00	2.50	3	3
IQR		0.60	0.67	0.67	1.00	1	0
Skewness		1.96	2.25	2.38	1.22	1.62	3.03
Kurtosis		4.09	6.19	6.85	0.22	1.74	10.19

a. Education: Education was measured as a categorical variable with six levels (as illustrated in Figure 4). Due to a small sample size in individual levels, educational level was collapsed into two categories, undergraduate (comprised of ADN, BSN, non-BSN, and LPN degrees) and graduate (comprised of MSN degrees and doctorates). The variable, Nurses Stigmatize HIV/AIDS patients, was compared to the two groups created by the new dichotomous educational variable with an independent sample t test. The independent variable was education. The dependent variable was Nurses Stigmatize HIV patients. The following hypothesis was tested regarding educational level:

Figure 4: Mean Nurses Stigmatize HIV Patients by dichotomous educational level.

H₁: An individual’s educational level is related to his or her experience of stigmatizing behavior.

Nineteen nurses with graduate degrees exhibited slightly more stigma, M = 1.44, SD = 0.54, compared to 27 nurses who held undergraduate degrees, M = 1.29, SD = 0.49. Results of the independent sample t test showed that the difference in Nurses Stigmatize HIV patients between undergraduate and graduate levels was not statistically significant, t (44) = -0.94, p = .352. Therefore, the hypothesis was rejected. Figure 4 illustrates the mean Nurses Stigmatize HIV Patients by dichotomous educational levels.

1. Age: To determine if age correlated with the extent to which Nurses Stigmatize HIV Patients, a Pearson correlation was generated. The following hypothesis was tested regarding age:

H₂: There is a correlation between age and the extent to which Nurses Stigmatize HIV/AIDs patients.

The correlation between age and the extent to which Nurses Stigmatize HIV patients was negligible and not statistically significant, r (44) = -.20, p = .182. Therefore, the hypothesis was rejected. Figure 5 illustrates a scatter plot of age and the extent to which Nurses Stigmatize HIV Patients.

1. Gender: To determine if the variable, Nurses Stigmatize HIV/AIDS patients differed by gender; the variable was compared with an independent sample t test. The independent variable was gender. The dependent variable was Nurses Stigmatize HIV Patients. The following hypothesis tested the variable of gender:

Figure 5: Scatter plot of age and the extent to which Nurses Stigmatize HIV Patients.

H₃: An individual’s gender is related to his or her experience of stigmatizing behavior.

Nine men and 37 women exhibited comparable stigma, men M = 1.35, SD = 0.59, women M = 1.35, SD = 0.49. Results of the independent sample t test showed that the difference in Nurses Stigmatize HIV patients between male and female nurses was not statistically significant, t (44) = 0.02, p = .983. Therefore, the hypothesis was rejected. Figure 6 shows the mean Nurses Stigmatize HIV patients by gender. 

Figure 6: Mean Nurses Stigmatize HIV patients by gender.

According to the National Rural Health Association (2014) [9], stigma can post a danger to individuals living with HIV/AIDS. This study examined several factors related to the perceptions of rural nurses who provide care for individuals living with HIV/AIDS. Based on the study findings of this study, nurses providing care in rural areas to individuals living with HIV/AIDS is minimal. Likewise, those providing care to individuals living with the disease and perceive stigma from their family members is also minimal. In both instances, there is no significant evidence of stigma. While there is no stigma, based upon quantitative methods of research, there is the opportunity to examine further using a qualitative method such as interviews to further engage the participants. The findings of this study are contrary to information obtained during the literature review, which suggested that stigma is more widespread and is a barrier to care for those living with the disease. 

This study was conducted primarily with nurses who provide care for individuals living in HIV/AIDS in rural areas. The opportunity exists to understand how attitudes of rural nurses compare to those practicing in urban areas. Ideally, since Mississippi is largely rural, the sample for urban nurses would be selected from a more densely populated state. The researcher recommends choosing a sample with a population similar to that of Mississippi.   

The majority of nurses participating in this study were African-Americans. In addition to understanding differences between African-American nurses and nurses who are of other nationalities or racial make-up, the opportunity also exists to understand perspectives based upon which specialty a nurse chooses to practice. Most nurses participating in this study were African-American.  Without further research amongst different races, it will not be possible to evaluate the overall effects of stigma.                     

Acknowledgements

The following individuals contributed to this study and have agreed to be named as such:

• Michael L. Jones, Ph.D., M.B.A., R.N. – Investigator
• Arlene J. Montgomery, Ph.D., R.N. – Dissertation Chair – Hampton University
• Melissa Gomes, Ph.D., A.P.R.N., P.M.H.N.P., F.N.A.P. – Dissertation Committee Member – Hampton University
• Dorothy P. Burns, Ph.D., R.N. – Dissertation Committee Member – Hampton University
• Zina T. McGhee, Ph.D. – Dissertation Committee Member (Biostatistician) – Hampton University
• Tangela N. Hales, Ph.D., R.N. – Editor – Hinds Community College

Funding Information

The investigator did not receive funding to conduct this study. This study was conducted as the investigator’s Dissertation at the Hampton University School of Nursing.

1. Centers for Disease Control and Prevention (CDC, 2017). HIV in the United States: At a Glance.
2. Mississippi State Department of Health 2014 Annual HIV Summary for Mississippi. 2016.
3. Hatzenbuehler ML, Phelan JC, Link BG. Stigma as a fundamental cause of population health inequalities. Am J Public Health. 2013; 103: 813-821.
4. Bureau of Primary Health Care HIV and Primary Care Integration. 2017.
5. Polit DF, Beck CT. Essentials of Nursing Research: Appraising evidence for nursing practice (9^th). Philadelphia, Lippincott, Williams & Wilkins. 2018.
6. Uys LR, Holzemer WL, Chirwa ML, Diamini PS, Greeff M, et al. The development and validation of the HIV/AIDS stigma instrument-nurse. AIDS Care. 2009; 21: 150-159.
7. Gliner JA, Morgan GA. Research methods in applied settings: An integrated approach to design and analysis. Erlbaum: Mahwah, NJ. 2000.
8. Cohen JW. Statistical power analysis for the behavioral sciences. (2^nd) Hillsdale NJ: Lawrence Erlbaum. 1988.
9. National Rural Health Association. HIV/AIDS in rural America: Disproportionate impact on minority and multicultural population. National Rural Health Association Policy Brief. 2014; 1-6.