The effect of professional education on the knowledge and attitudes of physical therapist and occupational therapist students about acquired immunodeficiency syndrome.

Key Words: Acquired immunodeficiency syndrome, Education, Intervention, Occupational therapy, Physical therapy.

Acquired immunodeficiency syndrome (AIDS) is one of the most complex and yet endemic diseases around the world. According to the World Health Organization, about 4.5 million adults worldwide have AIDS; 18 million adults and 15 million children are infected by the human immunodeficiency virus (HIV).[1] By the year 2000, between 30 and 40 million people worldwide will be HIV positive.[1] In the United States, as of December 1995, over 1 million people were HIV positive, with 513,486 cases of AIDS and 319,849 deaths reported.[2]

Public health education continues to be a strategy used to combat the spread of HIV infection. Although the pathophysiology and modes of transmission of HIV are now well-known, many health care providers, like the general population, are still fearful of working with people with HIV infection and AIDS. Whether improvement in knowledge about AIDS could positively influence rehabilitation workers' willingness to treat people with AIDS is not known.

Several authors[3-16] have shown that a comprehensive program of AIDS education has a positive effect on changing attitudes and beliefs about the disease. Lawrence and Lawrence[17] found that professional nurses with graduate degrees had more knowledge and more positive attitudes about treating people with AIDS than did most baccalaureate nursing students, liberal arts college students, and nonnurse adults. Similarly, other researchers[18,19] showed that nursing students with poor knowledge about AIDS perceived greater occupational risk of HIV infection and had more negative attitudes about providing services for people with AIDS than did students with high knowledge about AIDS.

Several studies have examined the effect of health education on knowledge, attitudes, and willingness to provide services for people with AIDS among physicians[3-8]; nurses[3,5,8-11]; and medical,[12,13] nursing,[13-15] and physical therapist[16] students. Some educators[4-11,14] believe that AIDS education designed for health care providers leads to an informed (knowledgeable) work force who will develop a positive attitude about HIV infection and AIDS and, therefore, will be more willing to treat these patients. There is currently a dearth of data to support this assumption.

In a recent cross-sectional study of students from 5 health care professions (30 physical therapist students, 35 occupational therapist students, 24 diagnostic medical imaging students, 12 health information management students, and 19 midwifery education students),[20] we found positive relationships between knowledge of AIDS and attitudes about AIDS (r=.56) and between attitudes about AIDS and a willingness to provide services for people with AIDS (r=.49). We found no relationship between knowledge about AIDS and a willingness to treat people with AIDS (r=-.16). We speculated that improvement in knowledge and attitude scores following a comprehensive program of AIDS education may not necessarily affect the health care provider's willingness to treat people with AIDS.

We designed this prospective study to evaluate physical therapist and occupational therapist students' knowledge, attitudes, and willingness to provide services for people with AIDS at the beginning of the students' professional education program, following a 5-hour AIDS education seminar, and at the end of their professional education program.

Materials and Method

Sample

All of the 30 physical therapist students and the 35 occupational therapist students admitted during the 1994-1995 academic year at the State University of New York Health Science Center at Brooklyn volunteered to participate in this study as part of the departments' ongoing curriculum evaluation.

The data of 4 physical therapist students and 12 occupational therapist students were excluded from statistical analyses due to incomplete information, These students failed to provide sociodemographic information or did not complete some sections of the questionnaire (n=6), provided inconsistent identification numbers (n=5), or had scheduling conflicts and were therefore unable to complete all 3 evaluations required in this study (n=5). Consequently, the sample for this prospective study consisted of 26 physical therapist students (mean age=28.1 years, SD=6.7, range=19-39) and 23 occupational therapist students (mean age = 26.7 years, SD = 6.0, range=19-41). The students' sociodemographic data, by discipline, are presented in Table 1.

Table 1.
Sociodemographic Characteristics of the Sample(a)

                                         Physical     Occupational
                                         Therapist      Therapist
                                         Students       Students
                                          (n=26)         (n-23)

Age (y)
  [bar] X                                  28.1           26.7
  SD                                        6.7            6.0
  Range                                    19-39          19-41
Sex
  Male                                     50.0           18.2
  Female                                   50.0           81.8

Ethnicity/race
  Caucasian                                69.7           71.2
  African American                          4.3            0.0
  Hispanic/Latino                          13.0            0.0
  Asian or Pacific Islander                 8.7            0.0
  Native American/Alaskan                   0.0            0.0
  Others/international                      4.3           22.8

Religious affiliation
  Protestant                                4.3            4.5
  Catholic                                 43.5           31.8
  Jewish                                   17.4           54.5
  No identification                        30.4            4.5
  Others                                    4.3            4.5

Marital status
  Married                                  20.8           19.0
  Single                                   79.2           71.5
  Divorced                                  0.0            9.5
  Widowed                                   0.0            0.0

Parental status
  Students with children                    8.3           17.4
  Students without children                91.7           82.6

All values are percentages, unless otherwise noted.

Educational Setting

The students in this study were educated in an urban public institution that uses an interdisciplinary model of education. The College of Health-Related Professions otters 6 baccalaureate courses and 6 certificate courses in various health care disciplines. The physical therapy and occupational therapy departments offer 2-year, upper-division curricula leading to the award of Bachelor of Science degrees.

The students in the physical therapy and occupational therapy programs take basic science courses (human gross anatomy, principles of biochemistry and physiology, human neuroanatomy, and neurophysiology of motor control), medical science courses (internal medicine, pediatrics, neurology, and orthopedics), and some professional courses (palpation laboratory, kinesiology, research methods, and psychiatry) together. In addition, the students participate in other required educational activities such as the AIDS education seminar and a colloquium on cross-cultural and international health care issues. About 25% of the various courses in the curricula of the physical therapy and occupational therapy departments are shared.

AIDS Education Seminar

Once a year, in the fall semester, the college provides an AIDS education seminar. Participation in the seminar is required. The seminar is designed to discuss ethical issues in patient care and to develop in students sensitivity and interpersonal skills relating to individuals who are HIV positive and people with AIDS.

The seminar consists of (1) a 1-hour lecture on ethical and legal issues in health care; (2) a 2-hour panel discussion of the treatment options by various health care providers (physicians, physical therapists, occupational therapists, nurses, and social workers) available to people with AIDS; (3) a 1-hour, small-group, interdisciplinary session of case study discussions led by a faculty member; and (4) a 1-hour case study session moderated by faculty members from each department (ie, physical therapy, occupational therapy, physician assistant, diagnostic and medical imaging, health information management, and midwifery education, with students attending sessions led by members of their own discipline).

As a result of the differences in the curriculum design between the physical therapy and occupational therapy departments, the students in this study participated in the AIDS seminar at different times during their professional education. The physical therapist students participated in the AIDS education seminar in October 1994, during their junior year. The occupational therapist students participated in October 1995, during their senior year. The format and presenters used during the AIDS seminar were kept the same for 1994 and 1995.

HIV- and AIDS-Related Contents in the Physical Therapy and Occupational Therapy Curricula

The physical therapy and occupational therapy curricula contained a 3-credit medical science course offered in the spring semester of the junior year. In this course, there were approximately 5 hours of lectures on AIDS and related topics. The lectures included material on AIDS-related pathophysiology, epidemiology, secondary infections, cancers, associated neurological problems, modes of transmission, universal precautions, isolation techniques, and medical management. The lectures were presented by physicians representing pediatrics, internal medicine, orthopedics, and neurology.

In the occupational therapy curriculum, in addition to the medical science course, approximately 10 hours of lectures were presented on the roles of the occupational therapist in the treatment of people with AIDS, psychosocial aspects of HIV infection and AIDS in adults and children, patients' confidentiality, and hospice care.

The physical therapist students, in addition to the medical science course, received about 10 hours of lectures on the pathology of HIV infection and the effect on various physiological systems. In addition, there were discussions of services provided by physical therapists and of ethical and legal (insurance and reimbursement) issues. The psychosocial aspects of the disease were discussed by a person who was HIV positive. A question-and-answer format was adopted during this class session.

Didactic materials, in both disciplines, were presented in the form of lectures, reading of journal articles, small-group discussions, and viewing of audiovisual tapes on HIV and AIDS. Learning was evaluated through written assignments and examinations. During their clinical affiliations, the physical therapist students and occupational therapist students were assigned to settings that included people with HIV or AIDS.

Experimental Design

A 2 (disciplines) X 3 (time frames) repeated-measures, quasi-experimental (time series) design[21] was used in this study. Students from the physical therapy and occupational therapy programs completed a questionnaire on 3 separate occasions: at the beginning of their professional education program, following the AIDS education seminar, and at the end of their professional education program. The questionnaire was designed to evaluate the students' knowledge about AIDS, their attitudes toward people with AIDS, and their willingness to provide services for people with AIDS. The questionnaire, for each discipline, was administered by the same instructor on the 3 occasions.

Pilot Study

In this study, we adapted the questionnaire used by Held[16] to monitor the students' knowledge about AIDS, their attitudes toward people with AIDS, and their willingness to treat people with AIDS. To determine the reliability of our measurements, we administered the questionnaire to 30 senior physical therapist students during March 1994. The questionnaire was administered on 2 occasions, with a test-retest interval of 5 weeks. The Pearson product-moment correlation coefficients obtained for the knowledge, attitude, and willingness subscales were .68, .83 and .76, respectively.

In 1993, Held[16] demonstrated the reproducibility of data obtained with the instrument used in a study of junior physical therapist students. A 1-week interval between tests was used to establish the test-retest reliability. Held reported Pearson product-moment correlation coefficients of .93, .82, and .80 for the knowledge, attitude, and willingness subscales, respectively. Our relatively lower Pearson correlation coefficients may be attributed to the longer test-retest interval of 5 weeks used in our study, as compared with Held's test-retest interval of 1 week.[21]

Research Questionnaire

The research questionnaire used in this study consisted of 2 major parts. Part 1 elicited sociodemographic information such as age, sex, ethnicity or race, religious affiliation, marital status, and parental status. Part 2 of the questionnaire contained items that evaluated the respondents' knowledge of AIDS, attitudes toward people with AIDS, and willingness to care for people with AIDS. Subscale 1 evaluated the respondents' knowledge about AIDS and consisted of 34 items on the pathophysiology, universal precautions, and prevention and treatment of AIDS. Subscale 2 consisted of 35 items designed to evaluate the respondents' attitudes toward people with AIDS. Subscale 3 presented 5 clinical scenarios, specific to each discipline, in which respondents were asked to rate their willingness to provide services for people with AIDS. Examples of items in each subscale are presented in Table 2.

Table 2.
Sample Items for the 3 Subscales of the Research Questionnaire(a)

Subscale 1: Knowledge About AIDS
  The AIDS virus is found in high concentrations in saliva, tears,
  and urine.
  The cancer most frequently seen among persons with AIDS is
  Kaposi sarcoma.

  Masks should be routinely worn when caring for all individuals
  with AIDS.
  Health care workers who are pregnant and use proper
  precautions are still at increased risk of contracting the AIDS
  virus.
  AIDS is caused by a retrovirus called HTLV III/LAV.

  Physical therapists and occupational therapists are not trained
  to treat the disabilities or physical limitations of persons with
  AIDS.

Subscale 2: Attitudes Toward Persons With AIDS
  I should have the right to refuse to care for a person with AIDS.
  If I cared for patients with AIDS, I would worry about putting
  my family, friends, and colleagues at risk.
  Physical therapists and occupational therapists who care for
  persons with AIDS should receive additional pay.
  I would not want to be assigned to persons with AIDS, because
  I do not feel competent to deal with their intense psychological
  needs.
  I have little sympathy toward drug users who acquire AIDS.
  Homosexuals who contract AIDS are getting what they deserve.
  I do not feel as comfortable providing services to gay women
  as I do women who are not identified as lesbians.

Subscale 3: Willingness to Provide Services for Persons
  With AIDS
  Frank is a patient with a diagnosis of AIDS and Pneumocystis
  carinii pneumonia. He has been referred for treatment
  consisting of pastural drainage, percussion, vibration, and
  breathing and coughing exercises. I would be willing to
  evaluate and treat the patient.
  Tim is a patient with a diagnosis of AIDS who has been
  referred for treatment of his limited hand function due to skin
  lesions (decubitis) and pain from peripheral sensory
  neuropathies. I would Be willing to treat Tim.

(a) AIDS=acquired immunodeficiency syndrome; LTLV III=human T-cell lymphotrophic virus, type III; LAV=lymphadenopathy-associated virus.

The statements in subscale 1 were framed to elicit "yes," "no," or "not sure" responses (Tab. 2). Only correct answers were counted, and "not sure" responses were not given any credit. The minimum and maximum scores for subscale 1 (knowledge about AIDS) were 0 and 34, respectively. A high score on subscale 1 of the questionnaire indicated good knowledge about AIDS.

For subscale 2 (attitudes toward people with AIDS), the students' rated their response on a 3-point Likert scale, ranging from strongly agree (1) to strongly disagree (5). The minimum and maximum scores for subscale 2 were 35 and 175, respectively. The items in the attitude subscale (Tab. 2) were worded negatively. The higher the subjects' total score, therefore, the more positive their attitudes were toward people with AIDS.[16]

The respondents rated the 5 case scenarios of subscale 3 (willingness to treat a person with AIDS) on a 5-point Likert scale, ranging on a continuum from strongly willing (1) to strongly unwilling (5). The minimum and maximum scores for subscale 3 were 5 and 25, respectively. In order to minimize the contamination and bias due to the social desirability phenomenon (ie, subjects' willingness and tendencies to behave according to the expected social norms)? the items on the willingness subscale (Tab. 2) were worded positively. The higher the subjects' total score, the less willing they were to treat people with AIDS.[16]

Procedure

The test instrument was administered during May 1994 to all newly admitted students in the physical therapy and occupational therapy programs. The questionnaire was administered during the first week of the semester during a regularly scheduled class session. Participation in the study was voluntary.

One of the investigators introduced the questionnaire to the students and provided specific instructions on how to complete it. The students were told to answer the items in the questionnaire as honestly and as accurately as possible. A time limit was not imposed, but the majority of the students completed the questionnaire within 20 minutes (approximately 15-30 minutes).

The questionnaire was administered again within a week after the completion of the 5-hour AIDS education seminar (ie, on the third day after the AIDS seminar in the physical therapy program and on the fifth day after the AIDS seminar in the occupational therapy program). Finally, the questionnaire was administered a third time to both groups during a regularly scheduled class during June 1996, within a week of completion of the requirements for their baccalaureate degree. At that time, the students would have completed over 20 weeks of clinical affiliations in various practice settings.

Data Reduction and Analysis

We obtained each student's responses for the 3 subscales of the questionnaire. We determined the number of correct responses on the items designed to evaluate their knowledge about AIDS (ie, subscale 1 of the questionnaire). Similarly, we summed the students' ratings separately for their responses to the items designed to evaluate their attitudes about people with AIDS (ie, subscale 2) and willingness to provide services for people with AIDS (ie, subscale 3).

To determine differences in the physical therapist and occupational therapist students' knowledge, attitude, and willingness scores at the 3 time frames (ie, at the beginning of their professional education program, following the AIDS education seminar, and shortly before graduation), the data were analyzed with a 2-factor repeated-measures analysis of variance (ANOVA). Significant main effects were probed with a Scheffe post hoc test. Scheffe simple cell means contrasts were used to probe all significant interaction effects.[23] Significant main effects were probed only when the interaction effects were not statistically significant. Only the simple cell means contrasts were reported when the interaction effect was significant.

We used the Scheffe post hoc method because of the unequal sample sizes of the groups. The Scheff6 procedure uses the F sampling distribution and, similar to the ANOVA, is robust with respect to non-normality and heterogeneity of variance. For all the statistical analyses, significant differences were fixed at .05 alpha level. Analyses were performed on the Macintosh microcomputer(*) using the StatView 513+ statistical software.([dagger])

Results

Knowledge About AIDS

At the beginning of the students' professional education program, the correct responses on subscale 1 of the questionnaire (knowledge about AIDS) ranged from 14 to 31 (X=24.4, SD=4.2) for the physical therapist students and from 14 to 31 (X=23.9, SD= 4.3) for the occupational therapist students. After the AIDS seminar, scores for knowledge about AIDS ranged from 18 to 32 (X=25.5, SD=3.8) for the physical therapist students and from 19 to 31 (X=27.0, SD=3.3) for the occupational therapist students. Following the educational seminar, knowledge about AIDS improved by 4.5% for the physical therapist students and by 13% for the occupational therapist students. At the time of graduation, the physical therapist students' scores for knowledge about AIDS ranged from 24 to 32 (X=27.9, SD=2.2) and the occupational therapist students' scores for knowledge about AIDS ranged from 21 to 32 (2=27.2, SD=3.0). There was an improvement of 14.3% for the physical therapist students and of 13.8% for the occupational therapist students.

To test the hypotheses that the improvements observed in the knowledge scores were not due to chance, inferential statistics (2-factor repeated-measures ANOVA) were used to analyze the data. The results of the ANOVA for knowledge scores are presented in Table 3. For clarity, the discipline x time frame interaction effect for the knowledge scores is plotted in Figure 1. The results of the Scheff6 simple cell means post hoc contrast for discipline x time frame interaction effect revealed no difference in knowledge about AIDS between the physical therapist and occupational therapist students at the beginning of their education program and at the time of graduation. Following the AIDS education seminar, the occupational therapist students had more knowledge about AIDS than the physical therapist students did. The students in both disciplines showed an improvement in their knowledge scores following the AIDS education seminar and at the end of their professional education program. No difference was found in the knowledge scores following the AIDS education seminar and at the time of graduation.

Table 3.
Results of the 2-Factor Repeated-Measures Analysis of
Variance for the Knowledge, Attitude, and Willingness Scores

                                            df             SS

Knowledge about AIDS(a)
  Disciplines (A)                            1              2.3
  Subject with groups                       47           1151.7
  Time frames (B)                            2            274.1
  A x B                                      2             38.6
  B x subject with groups                   94            488.0
Attitudes toward people with AIDS
  Disciplines (A)                            1           3180.6
  Subject with groups                       47          80376.3
  Time frames (B)                            2           2154.8
  A x B                                      2            563.4
  B x subject with groups                   94          11460.5
Willingness to treat people with AIDS
  Disciplines (A)                            1            189.7
  Subject with groups                       43           1584.3
  Time frames (B)                            2              4.9
  A x B                                      2              2.5
  B x subject with groups                   86            458.5

                                            MS        F         P

Knowledge about AIDS(a)
  Disciplines (A)                           2.3     0.10      .7584
  Subject with groups                      24.5
  Time frames (B)                         137.0    26.39      .0001
  A x B                                    19.3     3.72      .0278
  B x subject with groups                   5.2
Attitudes toward people with AIDS
  Disciplines (A)                        3180.6     1.86      .1791
  Subject with groups                    1710.1
  Time frames (B)                        1077.4     8.84      .0003
  A x B                                   281.7     2.31      .1048
  B x subject with groups                 121.9
Willingness to treat people with AIDS
  Disciplines (A)                         189.7     5.15      .0283
  Subject with groups                      36.8
  Time frames (B)                           2.5     0.46      .6312
  A x B                                     1.3
  B x subject with groups                   5.3     0.24      .7891

(a) AIDS=acquired immunodeficiency syndrome.

Attitudes Toward People With AIDS

At the beginning of the students' professional education program, the total scores on subscale 2 of the questionnaire (attitudes toward people with AIDS) ranged from 81 to 158 (X=134.1, SD=19.7) for the physical therapist students and from 71 to 168 (2=120.0, SD=28.0) for the occupational therapist students. Attitude scores after the AIDS seminar ranged from 48 to 166 (X=129.6, SD=25.2) for the physical therapist students and from 64 to 169 (X=128.2, SD=27.0) for the occupational therapist students. Attitude scores declined by 3.4% for the physical therapist students and improved by 6.8% for the occupational therapist students. At the end of the students' professional education program, attitude scores ranged from 80 to 174 (X= 144, SD = 21.1) for the physical therapist students and from 63 to 166 (X= 126, SD = 29.1) for the occupational therapist students. There was an improvement of 7.4% for the physical therapist students and of 5% for the occupational therapist students.

Table 3 presents the results of the 2-factor repeated-measures ANOVA for attitudes toward people with AIDS. The scores of students in both disciplines showed improvement in their attitudes toward people with AIDS at the end of their professional education program (Fig. 2). The attitude scores obtained following the AIDS education seminar were not different from the scores obtained at the beginning of the professional education program. Improvement, however, was observed between the attitude scores obtained following the AIDS seminar and the scores obtained at the end of the professional education program.

[Figure 2 ILLUSTRATION OMITTED]

Willingness to Provide Services for People With AIDS

At the beginning of the students' professional education program, the total scores on subscale 3 of the questionnaire (willingness to treat people with AIDS) ranged from 0 to 25 ([bar]X=8.9, SD=5.6) for the physical therapist students and from 5 to 19 ([bar]X=11.2, SD=3.6) for the occupational therapist students. After the AIDS education seminar, the total scores for willingness to treat people with AIDS ranged from 0 to 18 ([bar]X=9.8, SD=5.0) for the physical therapist students and from 5 to 16 ([bar]X=10.4, SD=3.4) for the occupational therapist students. At the end of the AIDS education seminar, the scores for willingness to treat people with AIDS declined by 10.1% among the physical therapist students and improved by 7.1% among the occupational therapist students.

At the end of the professional education program, the scores for willingness to treat people with AIDS ranged from 5 to 14 ([bar]X=8.4, SD=3.1) for the physical therapist students and from 5 to 18 ([bar]X=11.0, SD=3.9) for the occupational therapist students. At the time of graduation, the scores for willingness to treat people with AIDS improved by 5.6% for the physical therapist students and by 1.8% for the occupational therapist students.

The results of the ANOVA for willingness to treat people with AIDS are presented in Table 3. The physical therapist students' scores showed that they were more willing to treat people with AIDS than their occupational therapy counterparts were. In both disciplines, the students' willingness to provide services for people with AIDS remained unchanged following the AIDS education seminar and at the end of the professional education program (Fig. 3).

[Figure 3 ILLUSTRATION OMITTED]

Although not an initial research objective of this study, we analyzed our data a posteriori to explore the effects of the students' sex and religious beliefs on their willingness to treat people with AIDS at the beginning of their professional education program, following the AIDS education seminar, and at the time of graduation (Tab. 4). The results of the 2-factor (sex x time frame) repeated-measures ANOVA indicated that willingness to treat people with AIDS was influenced (F=4.79, P [is less than] .05) by the students' sex. The Scheffe post hoc analysis revealed that female students (n=30) were less willing to provide care for people with AIDS than male students (n=15) were at the beginning of their professional education program, following the AIDS education seminar, and at the time of graduation.

Table 4. Influence of Sex and Religious Beliefs on Physical Therapist and Occupational Therapist Students' Willingness to Treat People With Acquired Immunodeficiency Syndrome (AIDS)

                                        df           SS           MS

Influence of sex
   Sex (A)                               1        177.6        177.6
   Subject with groups                  43       1596.4         37.1
   Time frames (B)                       2          4.8          2.5
   A x B                                 2          3.8          1.9
   B x subject with groups              86        457.3          5.3
Influence of religious affiliation
   Religion (A)                          4        577.2        144.3
   Subject with groups                  40       1196.8         29.9
   Time frames (B)                       2          4.9          2.5
   A x B                                 8         43.6          5.4
   B x subject with groups              80        417.5          5.2

   df                                    F            P

Influence of sex
   Sex (A)                            4.79        .0342
   Subject with groups
   Time frames (B)                    0.46        .6304
   A x B                              0.36        .7006
   B x subject with groups
Influence of religious affiliation
   Religion (A)                       4.82        .0029
   Subject with groups
   Time frames (B)                    0.47        .6251
   A x B                              1.04         .411
   B x subject with groups

The results of the 2-factor (religious belief x time frame) repeated-measures ANOVA showed differences (F=4.82, P [is less than] .01) in the willingness scores based on different religious affiliations (Tab. 4). The Scheffe post hoc analysis showed that students identifying themselves as Jewish ([bar]X= 12.3) or Catholic ([bar]X=8.5) were less willing to care for people with AIDS than were students who identified themselves as Protestant ([bar]X=5.2) or those with no identifiable religious affiliation ([bar]X=8.4). These findings should be interpreted with caution because of the small sample size, the unequal distribution of male students (n=15) and female students (n=30), and the wide disparity in numbers of students with different religion beliefs. The majority of the students in our study belonged to the Jewish (n=16) and Catholic (n=16) faiths. Nine students did not indicate their religious affiliation, and only 2 students each identified themselves as Protestant and "other."

Discussion

This study was designed to evaluate the influence of an AIDS education seminar and the professional education offered to physical therapist and occupational therapist students on their knowledge about AIDS, their attitudes toward people with AIDS, and their willingness to provide care for people with AIDS. Although the AIDS education seminar in this study was implemented at different points in the education of the students, we found that the 5-hour educational program improved the students' knowledge about AIDS. The intervention, however, did not affect the students' attitudes toward people with AIDS or their willingness to treat people with AIDS. We found improvements in the students' attitudes toward people with AIDS at the end of the professional education program. The courses offered after the AIDS education seminar including clinical affiliation experiences may have positively influenced the students' attitudes. Our findings suggest that the AIDS education seminar may assist in influencing students' attitudes toward people with AIDS but does not have measurable effects on their attitudes after 1 week.

The occupational therapist students, following the AIDS education seminar, had more knowledge about AIDS than the physical therapist students did. This finding may be attributed to the different time frames at which the students in the 2 disciplines participated in the seminar. The occupational therapist students participated in the AIDS education seminar in their senior year after their first clinical affiliation and after the medical science course, which contained information on HIV infection and AIDS. The physical therapist students participated in the AIDS education seminar in their junior year, prior to taking the medical science course, and they had no clinical experience. Although the format used and instructors who participated in the AIDS education seminar were the same in 1994 and 1995, the differences in attitude scores between the 2 disciplines may, in part, be attributed to the varying effectiveness of the instructional methods used and the interactions between the students in both years.

Our findings partially agree with those of Held,16 who evaluated the effects of a 4-hour classroom-based lecture on physical therapist students' knowledge, attitudes, and willingness to treat people who have AIDS. The students assigned to the experimental (ie, AIDS education) group in her study showed improvement in knowledge. about AIDS (35.1%), more positive attitudes toward people with AIDS (5.7%), and more willingness to treat people with AIDS (12%) following the intervention. The control group showed no change in knowledge, attitudes, and willingness to work with people with AIDS. At the end of the AIDS seminar, the physical therapist students' knowledge about AIDS improved by 4.5%, their attitudes toward people with AIDS declined by 3.4%, and their willingness to provide services for people with AIDS declined by 10.1%. The outcomes obtained for the physical therapist students in our study, at the end of the AIDS education seminar, were small compared with the changes reported by Held.[16] The effectiveness of the AIDS intervention program implemented by Held may be the reason for these differences.[16]

The mean pretest knowledge, attitude, and willingness scores for the experimental group in Held's study[16] were 21.4 (SD=3.9), 116.7 (SD=18.9), and 11.5 (SD=3.5), respectively. In our study, the physical therapist students' initial mean knowledge, attitude, and willingness scores were 24.4 (SD=4.2), 134.1 (SD=19.7), and 8.9 (SD=5.6), respectively. The smaller changes that we observed, as compared with those reported by Held,[16] may be due, in part, to our students' higher scores at the beginning of their professional education program. Subjects with extremely high scores tend to regress toward the mean? We believe that, on admission to the physical therapist education program, our students are generally well informed about HIV and AIDS concepts. The majority of the items in the knowledge section of the questionnaire were covered in some of the courses (ie, anatomy, physiology, and microbiology) required for admission into the program.

Our findings indicate that the professional education offered to the students improved their knowledge about AIDS and positively enhanced their attitudes toward people with AIDS. The students' willingness to provide services for people with AIDS, however, remained unchanged. These findings suggest that improved knowledge exerts a salutary effect on attitudes but no effect on the willingness to treat people with AIDS. The lack of change in the students' willingness to treat people with AIDS at the end of the AIDS education seminar and at the time of graduation may be due to the high scores obtained at the beginning of the professional education program.

We found the physical therapist students we studied were more willing than their occupational therapy peers to care for people with AIDS. We attributed this finding to the differences in the students' religious beliefs and to the disparity in the gender distribution in the 2 disciplines.[20] The results of the a posteriori analyses showed that female students and students of conservative religious faiths were less willing to provide services for people with AIDS. Over 80% of the occupational therapist students in our study were female, 55% were Jewish, and 32% were Catholic (Tab. 1). About 90% of the occupational therapist students who identified themselves as Jewish were of the Orthodox Jewish faith. The physical therapist students were proportionately (50% each) divided between both sexes, 44% were Catholic, and 30% did not declare their religion.

The codes of ethics of the American Physical Therapy Association and the American Occupational Therapy Association forbid discrimination against colleagues and patients. Therapists cannot, therefore, ethically refuse to work with a particular person based on their diagnosis. Despite this ethical responsibility, some students expressed some hesitancy to treat people with AIDS. We cannot exclude the possibility that more studies would have been negative if the students were not aware of their ethical responsibility.

The construct "willingness to treat" may have more influence on the position chosen by the students when they are ready to accept employment. Graduates who are more willing to treat people with AIDS may selectively seek out positions where they perceive they are likely to be able to work with this population. Graduates who are less willing to treat people with AIDS, however, may accept positions where they perceive less likelihood of providing services to this population. Furthermore, a therapist's "willingness to treat" may initially affect the way he or she approaches a person with AIDS and the quality of care provided.

At the end of the professional education program, scores for knowledge about AIDS improved by 14.3% for the physical therapist students and by 13.8% for the occupational therapist students. Attitudes toward people with AIDS improved by 7.4% for the physical therapist students and by 5% for the occupational therapist students. We believe the change is worthwhile despite the modest improvement obtained. The costs required to implement the educational intervention are relatively minimal. The physical and human resources needed are (1) audiovisual aids used during the lecture component of the AIDS education seminar, (2) commitment of the health care providers who participate in the panel discussion during the AIDS education seminar, and (3) faculty time required for the 10 hours of classroom instruction on HIV and AIDS contents in the curriculum.

Areas for Future Study

Although research indicates that a comprehensive education intervention is beneficial for improving knowledge about AIDS,[3-19] there is currently a paucity of information on the effectiveness of the various teaching methods. To date, only one published study6 has evaluated the most effective teaching methods used in AIDS education. Lewis and colleagues[6] compared the efficacy of presenting AIDS information in printed materials, audiocassettes, and videocassettes on physicians' knowledge base in caring for persons with AIDS. An improvement was noted in the physicians' knowledge base. Unfortunately, none of these methods of educational delivery were found to be more effective than another. In our study, a combination of lectures and small-group discussions was implemented during the AIDS education seminar. Follow-up studies could investigate which of the instructional methods contributed to the improved knowledge observed following the AIDS education seminar.

Two major limitations of our study were the small sample size and the fact that all students came from one urban public university in the northeastern United States. Our findings, therefore, should be interpreted with caution. Further studies with larger sample sizes and student participants from other parts of the country are needed.

Conclusions

The results of our study indicate that, for a cohort of physical therapist and occupational therapist students, knowledge about AIDS and attitudes toward people with AIDS improved at the end of the students' professional education program. In both disciplines, the students' willingness to provide services for people with AIDS remained unchanged following an AIDS education seminar and at the end of their professional education program. We surmised that "willingness to provide care" is a more enduring, but difficult, construct to change.

References

[1] World Health Organization: Monthly Report. Geneva, Switzerland: World Health Organization; January 1996.

[2] Morbidity and Mortality Weekly Report. Atlanta, Ga: Centers for Disease Control and Prevention; 1996.

[3] O'Donnell L, O'Donnell GR. Hospital workers and AIDS: effects of in-service education on knowledge and perceived risks and stresses. NY State J Med. 1987;87:278-280.

[4] Gerbert B, Maiguire B, Boder V, et al. Changing dentists' knowledge, attitudes, and behaviors relating to AIDS: a controlled educational intervention. J Am Dent Assoc. 1988;116:851-854.

[5] Harnett SM. A hospital-wide AIDS education program. Journal of Continuing Education in Nursing. 1987;18(2):64-67.

[6] Lewis CE, Freeman HE, Kaplan SH, Corey CR. The impact of a program to enhance the competencies of primary care physicians in caring for patients with AIDS. J Gen Intern Med. 1986;1:287-294.

[7] Feit LR, Melzer SM, Vermund SH, Shelov SP. The impact of an AIDS symposium on attitudes of providers of pediatric health care. Acad Med. 1990;65:461-463.

[8] Wertz DC, Sorenson JR, Liebling L, et al. Knowledge and attitudes of AIDS health care providers before and after education programs. Public Health Rep. 1987;102:248-254.

[9] Young EW. Nurses' attitudes towards homosexuality: analysis of change in AIDS workshops. J Contin Educ Nurs. 1988;19(1):9-12.

[10] Armstrong-Esther C, Hewitt WE. The effects of education in nurses' perception of AIDS. J Adv Nurs. 1990;15:638-651.

[11] Flaskerud JH, Lewis MA, Shin D. Changing nurses' AIDS-related knowledge and attitudes through continuing education. J Contin Educ Nurs. 1989;20(4):148-154.

[12] Goldman JD. An elective seminar to teach first-year students the social and medical aspects of AIDS. J Med Educ. 1987;62:557-561.

[13] Ficarrotto TJ, Grade M, Bliwise N, Irish T. Predictors of medical and nursing students' levels of HIV-AIDS knowledge and their resistance to working with AIDS patients. Acad Med. 1990;65:470-471.

[14] Williams RD, Benedict S, Pearson BC. Degree of comfort in providing care to PWAs: effect of a workshop for baccalaureate nursing students. J Nurs Educ. 1992;31:397-402.

[15] Strauss RP, Corless IB, Luckey JW, et al. Cognitive and attitudinal impacts of a university AIDS course: interdisciplinary education as a public health intervention. Am J Public Health. 1992;82:569-572.

[16] Held SL. The effects of an AIDS education program on the knowledge and attitudes of a physical therapy class. Phys Ther. 1993;73:1.56-164.

[17] Lawrence SA, Lawrence RM. Knowledge and attitudes about acquired immunodeficiency syndrome in nursing and nonnursing groups. J Prof Nurs. 1989;5:92-101.

[18] Lester L, Beard B. Nursing students' attitudes about AIDS..] Nurs Educ. 1988;27:399-404.

[19] Jemmott LS, Jemmott JB 3d, Cruz-Collins M. Predicting AIDS patient care intentions among nursing students. Nurs Res. 1992;41;172-177.

[20] Balogun JA, Kaplan MT, Hoeberlein-Miller TM, et al. Knowledge, attitudes, and willingness of junior health care professional students to provide service for patients with acquired immunodeficiency syndrome. Journal of Physical Therapy Education. 1998;12(1):57-64.

[21] Currier DP. Elements of Research in Physical Therapy. 3rd ed. Baltimore, Md: Williams & Wilkins; 1990.

[22] Anastasi A. Psychological Testing. 5th ed. New York, NY: Macmillan Publishing Co Inc; 1982.

[23] Marascuilo IA, Levine JR. Appropriate post hoc comparisons for interaction and nested hypotheses in analysis of variance designs: the elimination of type IV errors. American Education Research Journal. 1970;7:397-320.

JA Balogun, PhD, PT, FACSM, is Professor and Chairman, Physical Therapy Program, and Associate Dean for Student Academic Affairs, College of Health-Related Professions, State University of New York Health Science Center, 450 Clarkson Ave, Box 16, Brooklyn, NY 11203 (USA) ([e-mail]). Address all correspondence to Dr Balogun.

Margaret T Kaplan, OTR, is Assistant Professor, Occupational Therapy Program, College of Health-Related Professions, State University of New York Health Science Center.

Teresa M Miller, PT, is Assistant Professor, Physical Therapy Program, College of Health-Related Professions, State University of New York Health Science Center.

This study was presented at the American Physical Therapy Association's Scientific Meeting and Exposition, May 30-June 2, 1997, San Diego, Calif. This article was submitted October 14, 1997, and was accepted March 5, 1998.

(*) Apple Computer Inc, 20525 Mariani Ave, Cupertino, CA 95014.

([dagger]) Brain Power Inc, 24009 Ventura Blvd, Suite 250, Calabasas, CA 91302.