AIDS knowledge among rehabilitation professionals.

Acquired immunodeficiency syndrome (AIDS) was first recognized in 1981. Since that time the number of new cases diagnosed each year has increased dramatically (Eisenberg, 1989). Along with the increased number of diagnosed cases per year is an increased level of concern on the part of the helping professions about the various needs of people with AIDS and the training/education required for care givers.

There was a reported 37% increase in the number of new AIDS cases diagnosed from October, 1990 to October, 1992 (Allen, 1993), and annual increases in new cases are expected to continue since current treatment is palliative at best (Eisenberg, 1989). As of October 1994, there were 429,923 diagnosed cases of AIDS in the United States (Arkansas Department of Health, 1995). An estimated 1 to 1.5 million Americans are infected with the Human Immunodeficiency Virus (HIV), the virus generally believed to cause AIDS (Centers for Disease Control, 1991).

The growth in the number of AIDS cases, the inclusion of AIDS patients under the protections of the Americans with Disabilities Act (ADA), and the reality that persons with AIDS are finding their way onto rehabilitation caseloads suggests that AIDS cases will place substantial demands on rehabilitation professionals in the near future (Backer, 1988). Most states have recognized AIDS as a disability by way of court decisions, formal policy, general agency practices or public statements (Rapoport & Zevnik, 1989), or acceptance of the Centers for Disease Control (CDC) view of HIV as a chronic illness. Consequently, the need and demand for vocational rehabilitation services will be growing in the coming years.

At the present time there appears to be little research dealing with rehabilitation professionals and AIDS. Computer searches of Index Medicus, PsycLIT, and Educational Resource Information Center (ERiC) identified few articles addressing rehabilitation professionals and AIDS. There were no articles found assessing knowledge about AIDS among rehabilitation professionals.

However, as with other professions, the knowledge level about AIDS held by rehabilitation professionals can affect services delivered. Similar studies within other professions have indicated a great deal of misinformation about AIDS (Cohen & Grace, 1989; Douglas, Kalman & Kalman, 1985; Kelly, St. Lawrence, Hood, Smith, & Cook, 1987a; Kelly et at., 1987b; Kelly et al., 1988; Sarvela & Moore, 1989; Vincent & Schkade, 1990).

The purpose of this study was to examine rehabilitation professionals' knowledge about the AIDS virus, transmission routes and to assess any statistically significant differences within demographic variables on AIDS knowledge.

Method

Instrumentation

The instrument selected for this study was a combined, modified version of the AIDS knowledge subsection of the National Health Interview Survey (NHIS) developed by the National Center for Health Statistics and the modes of transmission section of the AIDS Questionnaire developed by Drs. Mark J. Kittleson and John S. Venglarcik. The NHIS instrument includes items on self-assessment of knowledge about AIDS, self-assessment of chances of getting the AIDS virus, primary source(s) of information on AIDS, and recent experience with blood donation.

In a similar study, the NHIS survey reported a .88 internal-consistency reliability rating using Cronbach's Alpha on the misinformation scale (Samuels, 1989). In another, similar study, the AIDS questionnaire developed by Kittleson and Venglarcik exhibited a Cronbach's alpha of .86, (Kittleson, Elliott, Hoalt & DeMattei, 1991).

Participants were asked to provide demographic data and to respond to a series of general information questions and to a series of questions about the modes of HIV infectious transmission. In addition, an open-ended comments section was included. On the general information section the possible responses included: true, false, and don't know. The possible choices in the modes of transmission section were verified and not verified. The general information and modes of transmission sections combined to yield a knowledge score with 28 possible correct answers.

Participants

The target population for this study was employed rehabilitation professionals in the United States. The rehabilitation professionals in the sample were employed in a variety of settings: state/federal vocational rehabilitation offices, private rehabilitation companies, universities, mental health centers, hospitals, vocational workshops, insurance companies, schools, correctional institutes, residential centers, disabilities rights organizations, manufacturing, and the Rehabilitation Service Administration.

The respondents consisted of 362 rehabilitation professionals who attended: an Illinois Rehabilitation Association (IRA) conference; an Arkansas Rehabilitation Association (ARA) conference; a Commission on Rehabilitation Counseling Certification (CRCC) conference in Seattle, Washington; a rehabilitation educational seminar in Colorado; extended Southern Illinois University (SIU) graduate-level rehabilitation classes in Springfield, IL and Indianapolis, IN; a training seminar held in Wisconsin; and an SIU on campus class for rehabilitation professionals working in the area of visual impairment. Questionnaires were also completed by the professional staff at an Arkansas sheltered workshop, a Kentucky vocational rehabilitation office and a nationwide private rehabilitation company. Data were collected from all ten Rehabilitation Service Administration (RSA) regions in the United States, and from Canada (9 responses).

Selected demographic characteristics of the participants are summarized in Table 1. The age range of the participants was 22 to 65, with a mean age of 41.9 years. Forty-five percent (n=163) of the respondents were in the age range from 40-49. Sixty-three percent (n=228) of the respondents were female. The highest educational degree was obtained prior to 1980 by 49% (n=178) of the respondents, with 11% (n=41) receiving their degree prior to 1970, and 38% (n=137) receiving their degree in the 1970s. Thirty-nine percent (n=141) of the respondents received their highest educational degree in the 1980s and 12% (n=43) received their last degree in the 1990s.

Table 1

Selected Demographic Characteristics of Respondents

Variable                   Grps              Freq      (%)
Age                        20-29               28      (8)
                           30-39              110      (30)
                           40-49              163      (45)
                           50+                 61      (17)

Level of Education         Associate's         18      (5)
                           Bachelor's         126      (35)
                           Master's           195      (54)
                           Doctorate           23      (6)
Job Title                  Counselor          190      (53)
                           Other              172      (47)

Work Setting               State/Fed. V.R.    139      (38)
                           Private Rehab.      36      (38)
                           Workshops           23      (6)
                           Mental Health       12      (3)
                           Insurance Co.        6      (2)
                           Hospital             4      (1)
                           University          28      (8)
                           Other               14      (4)
Gender                     Male               134      (37)
                           Female             228      (63)

Fifty-three percent (n=190) of the respondents identified their job title as rehabilitation counselor. The 172 respondents who fell under the Other group heading were: advocates (7); consultants (33): technologists (6): vocational evaluators (6); management/supervisors (81); educators (23); rehabilitation nurses (4): social service specialists (3); rehabilitation business relations specialists (5); trainers (2). Two responses were illegible.

Forty-four percent (n=160) of the respondents reported that they had attended or participated in an AIDS workshop/inservice within the year prior to the study. Eighty-nine percent (n=323) answered affirmatively to wanting more AIDS educational programs and/or resources. When questioned as to whether the topic of AIDS had been taught during their educational coursework, only 14% (n=50) responded positively.

Eighty-two percent (n=297) of the respondents reported that they anticipate providing services for persons with AIDS, while 38% (n=137) responded that they have already provided services to persons with AIDS.

Data Collection

Following a pilot-test of the questionnaire, data were collected by distributing the questionnaires (which were in booklet form) at the aforementioned conferences, classes, and facilities. A return box was provided for the respondents at the conferences. Respondents at the other collection points were asked to return the surveys to the individual who distributed the questionnaires. Included on the cover of the questionnaire was a cover letter which included a brief explanation of the purpose of the study, an emphasis on the anonymity of participation, an estimated amount of time that it took to complete the questionnaire, and the voluntary nature of participation. In the instructions for the survey, the participants of the conferences were requested to return the completed questionnaires to the box designated as the survey return box. At both the ARA and IRA conferences, the questionnaires were distributed at the time of registration. The surveys were included in the registration packet at the CRCC conference. The rest of the completed surveys were collected after obtaining permission from respective authorities and informing the respondents that they had the opportunity to participate voluntarily and anonymously, in a research project about AIDS.

Results

Findings

A descriptive analysis of the knowledge level evidenced by the respondents indicated a mean knowledge score of 24.3 out of a possible 28. The range of correct responses in the knowledge section was from 10 to 28. The standard deviation was 2.5. An item analysis of the rehabilitation professionals' responses to each knowledge item is presented in Table 2.

Ninety-nine percent (n=360) of the respondents recognized that one cannot tell if people have the AIDS virus just by observation and that there is no cure for AIDS at present. Also, 99% (n=359) recognized that the sharing of intravenous (injectable) needles was a verified form of transmitting the AIDS virus.

However, some survey questions did not elicit a high percentage of accurate responses. For instance, 56% (n=203) of the respondents were unable to identify breast milk as a verified mode of transmission of the AIDS virus. Fifty-one percent (n=184) incorrectly believed that biting and breaking skin was a verified mode of transmission. Forty-five percent (n=164) did not recognize that the AIDS virus can damage the brain and 38% (n=137) incorrectly believed that AIDS usually leads to heart disease. Finally, 22% (n=79) did not recognize that tongue or "wet" kissing is not a verified mode of transmission and 27% (n=98) did not know that father to fetus is not a verified mode of transmission.

Demographic Significant Differences

Statistically significant results using a One-way Analysis of Variance and t-tests were found within three of the demographic variables on the knowledge score. The three were age, year the respondents received their last degree, and attendance at an AIDS inservice. Demographic variables in which statistically significant differences were not found were education level, primary [TABULAR DATA FOR TABLE 2 OMITTED] work setting, job title, whether the professional has provided services for persons with AIDS, and employment in a rural or urban setting. An investigation into age on the knowledge scores, (see Table 3) through a post hoc analysis using the Tukey test with a critical difference of 1.15, revealed that the 20-29 year old respondents differed significantly on their overall knowledge scores from the 50+ year old respondents (F=5.75, p[less than].05). The 20-29 year old respondents had a mean knowledge score of 25.2, and the 50+ respondents had a mean score of 23.2. The Tukey test also revealed that the 30-39, and 40-49 year old respondents were statistically significantly more knowledgeable than the 50+ year group.

The results of determining significance by the year of last degree on the knowledge score are summarized in Table 4. Statistical significance was found using a One-way Analysis of Variance (F=3.962, p[less than].05); a Tukey post hoc investigation with a critical difference of 1.11 found a significant difference on knowledge scores between the respondents who received their last degree in the 1990s and those who received their last degree in 1979 or earlier. Those individuals who received their degrees after 1990 had higher scores than pre-1980 graduates.

Table 5 summarizes knowledge score differences between respondents who attended an inservice on AIDS and those who had not. Respondents who attended an inservice on AIDS were found to be more knowledgeable about AIDS than respondents who had not attended an AIDS inservice, (t=2.234, p[less than].05).

Summary, Discussion and Recommendations

The data from the item analysis of knowledge questions (Table 2) indicated that rehabilitation professionals did not have complete knowledge about AIDS. The mean knowledge score was 24.3 out of a possible 28.

Some confusion on the part of the rehabilitation professionals' knowledge about secondary problems associated with AIDS was evidenced as 45% of the respondents failed to recognize that the AIDS virus can damage the brain. It is estimated that 90% of persons with AIDS have evidence of the AIDS virus in the brain at the time of their death, and as many as 25% of persons with AIDS may present neurological problems before the development of any of the opportunistic infections (Bocellari, Kain, & Shore 1989). Thirty-eight percent of the respondents failed to recognize that AIDS usually does not lead to heart disease.

The knowledge level of the rehabilitation professionals from the subsection of the questionnaire addressing verified modes of HIV transmission was limited also. The percentage of rehabilitation professionals who correctly identified breast milk as a mode of HIV transmission (44%) falls between the percentages of correct responses from physicians (39.8%) and Ph.D.s (51.2%) found in a similar study (Kittleson & Venglarcik, 1990). Forty nine percent of the rehabilitation professionals knew that biting and breaking skin was not a verified mode of HIV transmission. The confusion over biting may result from associating AIDS with hepatitis, since hepatitis can be transmitted through biting. It may also be associated with past sensational media reports concerning prisoners biting correctional officers. The virus was not transmitted during these events, yet that information was not reported in follow-up stories. Other examples of ambiguity over the role of human saliva in transmitting AIDS were found. For example, 78% of the rehabilitation professionals correctly responded that tongue or "wet" kissing is not a verified mode of HIV transmission and 84% correctly identified CPR on humans as a non-verified mode of HIV transmission, consequently 22% and 16% of the respondents incorrectly responded to the respective modality concerns.

Table 3

Test of Statistical Significance of AIDS Knowledge by Age of
Rehabilitation Professionals.

Source               df      SS       MS        F        Fcv
Between Grps          3    103.56   34.52    5.75(*)    2.60
Within Grps         358   2146.32    5.9
Total               361   2249.88

* Statistically significant at the .05 alpha level.

Mean Knowledge Scores by Age
Age            Score
20-29          25.2
30-39          24.5
40-49          24.5
50+            23.2
Table 4

Test of Statistical Significance of AIDS Knowledge by the Year
Rehabilitation Professionals Received their Last Degree.

Source            df     SS        MS      F         Fcv
Between Grps      3     72.30    24.10   3.962(*)    2.60
Within Grps     358   2177.58     6.08
Total           361   2249.88

* Statistically significant at the .05 alpha level.

Mean Knowledge Scores by Year of Last Degree

Year                             Score

1969[less than or equal to]      23.7
1970s                            24
1980s                            24.6
1990+                            25.1

Seventy seven percent correctly identified having sexual intercourse with animals as a non-verified mode of HIV transmission. The confusion on the part of the 23% who answered incorrectly may be due to reports that monkeys in Africa and Asia have been infected with a virus similar to AIDS, known as Simian Immunodeficiency Virus (SIV) (Essex & Kanki 1988).

Table 5

Test of Statistical Significance of AIDS Knowledge by Attendance of
an AIDS Inservice of Rehabilitation Professionals.

Variable      N      Mean     SD     df     t          tcv
Yes          160    24.66    2.30    360   2.234(*)   1.645
No           202    24.07    2.62

* Statistically significant at the .05 alpha level.

There were significant differences in the knowledge level among the different age classifications as reported in Table 3. All of the younger respondents scored significantly higher than the 50+ age group. This finding coincides with similar results of Kittleson and Venglarcik (1990) which also indicated that younger health care workers had better knowledge about the transmission of HIV, compared to older health care workers.

Significant difference in regards to knowledge was also noted according to the year the respondents received their last degree. Rehabilitation professionals who received their last degree in the 1990s were significantly more knowledgeable about AIDS than respondents who received their last degree in the 1970s or earlier. One contribution to this finding may be associated with the data that younger respondents scored higher on knowledge than older respondents. Another contribution to the difference may be the quality and quantity of coursework addressing the AIDS topic. Respondents who studied AIDS in the 1990s most likely have more accurate and in depth AIDS information than respondents who attended school in earlier years. Earlier textbooks did not address the topic of AIDS since the disease was not recognized until 1981 (Eisenberg, 1989).

Rehabilitation professionals who have attended an AIDS workshop and/or inservice within the year prior to the study were more knowledgeable than respondents who did not, however fewer than half of the respondents (44%) attended a workshop. This finding is similar to one by Samuels (1989) who found that law enforcement officers who participated in a recent AIDS program held higher knowledge levels about AIDS than officers who did not participate.

Issues related to health care and rehabilitation services for individuals with AIDS have become increasingly important at all levels. Indeed, President Clinton, in his 1990 Arkansas gubernatorial campaign, specifically called for rehabilitation services involvement in the provision of services for people with AIDS ("Clinton, Nelson", 1990). In 1988, Backer suggested that rehabilitation caseloads would increasingly include individuals with AIDS, a notion recently reiterated by All and Fried (1994).

However, the incomplete and inaccurate knowledge base concerning AIDS among rehabilitation professionals suggests important implications for the rehabilitation training and for further research. As the numbers of individuals with AIDS grow in rehabilitation caseloads, counselors will be called upon to provide unique and often unfamiliar services (All & Fried, 1994). AIDS counseling will include such diverse topics as; AIDS/HIV specific counseling, high risk sexual behavior and drug consumption counseling, and work potential and retention counseling. In the later stages of the disease process, independent living loss, and grief counseling may predominate. Counselors working with individuals with AIDS may face difficult ethical dilemmas as clients straggle with issues concerning disclosure and non-disclosure of disease status to friends, family, employers, care givers, and others (All & Fried, 1994; Benshoff, 1990). The attitudes and beliefs of significant others may have a profound impact on the rehabilitation process.

The results of this study suggest several new directions for rehabilitation education. At the preservice level AIDS education-should be incorporated in both medical aspects and psychosocial aspects of disability courses. Clearly counselors will need additional information about disease transmission and progression concerning the psychological and societal impact of AIDS. Moreover, vocationally oriented courses addressing AIDS are a necessity. Evidence from a major urban counseling center serving individuals with HIV and AIDS suggests that job retention issues are of paramount concern (W. Fitzgerald, personal communication, September 14, 1994).

Rehabilitation professionals who attended a post-service training session on AIDS had significantly higher scores, clearly suggesting the importance of continuing education. Individuals who completed their preservice training prior to the 1990s are the group most in need of additional training according to these data.

A substantial percentage (89%) of the study respondents indicated a need for additional AIDS information. Although general information on AIDS is available from a variety of resources, there is relatively little rehabilitation-specific information. This deficit could be remedied through a national meeting on rehabilitation-specific AIDS related issues or through a special issue on AIDS in one of the mainstream rehabilitation journals.

This was a seminal study exploring knowledge about AIDS among rehabilitation professionals. Further exploration is required to define the rehabilitation-specific AIDS knowledge base. Moreover this study used a sample of convenience and consequently the results may not be generalizable to all settings which precluded comparison of regional distinctions and urban-rural differences. A randomized study would enhance generalizability.

References

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