The effects of an AIDS education program on the knowledge and attitudes of a physical therapy class.

In January 1992, the Centers for Disease Control reported over 1 million Americans infected with the human immunodeficiency virus (HIV), 206,392 diagnosed with acquired immunodeficiency syndrome (AIDS), and 133,232 having died from the disease.[1] Human immunodeficiency virus infection and AIDS have become a nationwide epidemic. Based on this information and the nature of this disease, many health care providers are advocating a team approach to the care of patients with AIDS.[2-5] Physical therapists are viable team members in the treatment of patients who have AIDS.

Several authors[2-5] have identified the role of physical therapists in treating the disabilities and impairments associated with AIDS and have indicated the need for physical therapy in the care of individuals with HIV infection and patients with AIDS. Galantino and Levy[2] have described many neurological disorders common in patients with AIDS and suggest early physical therapy intervention to improve and prolong the quality of life of individuals with HIV infection. Harris-Copp[3] and Anderson[4] emphasize the need for physical therapy intervention for children with HIV infection, who, in addition to Aids-related secondary infections, usually exhibit developmental delay and neurological involvement. Hopp and Rogers[5] describe the various aspects of AIDS and the role of allied health professionals, including physical therapists, in the care of patients with AIDS.

Several studies have shown a low level of AIDS knowledge, negative attitudes toward patients with AIDS, and an unwillingness to treat patients with AIDS among health care providers; however, minimal information can be found regarding this topic for physical therapists or physical therapy students. Studies involving physicians, nurses, and dentists[6-10] found variable to unsatisfactory AIDS knowledge levels and overall negative attitudes toward patients with AIDS. Two descriptive studies of physical therapists reported poor knowledge of participants in key aspects of AIDS.[11,12] Brissette et al[11] found no significant difference in the level of AIDS knowledge relative to the level of physical therapy work setting or mode of education, and Sweesy[12] found no significant difference in the level of AIDS knowledge related to years of physical therapy practice or number of patients with AIDS treated. With this preliminary information, it appears that patients with AIDS may not be receiving optimal care from empathetic health care workers. The majority of these researchers recommend at least fact-based AIDS education for all levels of health care staff.

Several authors[13-21] have reported significant improvement of AIDS knowledge and attitudes toward patients with AIDS following some type of educational intervention. Again, this research is primarily limited to hospital workers, dentists, nurses, physicians, and medical and nursing students.

O'Donnell and O'Donnell[13] surveyed hospital workers, including registered nurses, technicians, house officers, licensed practical nurses and aides, and social services personnel, before and after institutional in-service training programs. The authors found that in-service training was associated with significant improvement in knowledge about AIDS transmission, and workers reported a reduction in stress, perceived risks of providing AIDS-related care, and negative attitudes toward patients with AIDS. Similarly, Wertz et al(14) evaluated 36 different AIDS education programs for 1,047 health care providers and found a significant improvement in AIDS knowledge and attitudes toward patients with AIDS after the education programs.

In an investigation of dentists, Gerbert et al[15] studied educational interventions such as AIDS bulletins, computerized feedback, and the use of conference calls with dental AIDS experts. Results showed the group receiving the educational interventions had a significant improvement in AIDS knowledge, attitudes toward treating patients with AIDS, and willingness to treat patients with AIDS.

Several researchers[16-18] have investigated AIDS knowledge and attitudes with nurses. Turner et al[16] showed that a 5-hour seminar focused on improving nurses' general AIDS knowledge and infection control procedures with a structured session on attitudes resolution relative to caring for patients with AIDS resulted in significant change in AIDS knowledge, infection control, and attitudes toward caring for patients with AIDS following the seminar. Young[17] reported a significant reduction in nurses' negative attitudes toward homosexuals following specifically designed AIDS workshops that had an emphasis on human sexuality. Harnett[18] noted an improvement in nurses' AIDS knowledge and level of confidence, with a decreased fear and negative attitudes associated with treating patients who have AIDS, following a lecture session with question and answer periods,

Lewis et al[19] attempted to study the effects of AIDS information presented in printed materials, audiocassettes, and videocassettes on physicians' competencies in caring for patients with AIDS. Although a significant improvement in the physicians' competencies was found, it could not be related to the use of the educational materials because actual use of the materials could not be documented. These authors suggest a direct approach to AIDS education.

The effects of a nursing course in hospice care was measured on undergraduate and graduate nursing students by Lev.[20] Results indicated the students who participated in the course had significantly fewer avoidance behaviors toward patients who are dying or alcoholic or who have psychiatric problems or AIDS. Goldman's[21] Study of medical students revealed those participating in AIDS lectures, television/documentary movie viewing, discussion sessions, and use of reading materials had overcome their fear of the disease, developed empathy for patients with AIDS, and understood a comprehensive approach to this complex disease.

There is a lack of published research that investigates physical therapists' or physical therapy students' knowledge about AIDS, attitudes toward patients with AIDS, or willingness to treat patients with AIDS following any type of educational intervention. Only one unpublished study in this area has been found to date.

Although significant lack of knowledge and predominantly negative attitudes exist among health care workers expected to treat patients who have AIDS, there is evidence that educational intervention yields improvement in both knowledge of AIDS and attitudes toward patients with AIDS as well as in the willingness to treat patients who have AIDS. Two studies[11,12] have indicated that physical therapists, similar to other health care professionals, have inconsistent knowledge about AIDS and poor attitudes toward patients with AIDS. Other authors[2-5] have identified the need for physical therapy in the team approach to the care of patients with AIDS. With limited knowledge and negative attitudes, however, physical therapists and physical therapy students may be ill prepared and sometimes unwilling to treat patients who have AIDS. Thus, establishing the areas in which physical therapists lack knowledge and feel uncomfortable toward patients with AIDS and the effects of education is an important step in providing optimal physical therapy care to patients with AIDS.

The purpose of this study was to determine (1) entry-level undergraduate physical therapy students' level of AIDS knowledge, attitudes toward patients with AIDS, and willingness to treat patients with AIDS and (2) the effect of an AIDS education unit on these students' knowledge about AIDS, attitudes toward patients with AIDS, and willingness to treat patients with AIDS. The research hypothesis for this investigation was that AIDS education will improve entry-level undergraduate physical therapy students' knowledge about AIDS, attitudes toward patients with AIDS, and willingness to treat patients with AIDS.

Method

Subjects

A sample of convenience of 103 entry-level undergraduate junior physical therapy students in one class attending courses at one institution volunteered to participate in the study. The institution is a private, 4-year, nonsectarian, coeducational college with a total enrollment of 1,707 students 71% female, 87% white). Each entering upper-division (junior-level) physical therapy class has 100 to 115 students. The sample consisted of 30 male subjects and 73 female subjects with an age range of 20 to 35 years X [bar] =22.1, SD=2.8). Other demographic characteristics were 94.9% of the subjects were single, 97% had no children, 91.9% were white, 29.8% were Protestant, and 59.6% were Catholic. Random assignment via a random digits table was used to divide the sample into an experimental group that received an AIDS education unit (n=51) and a control group that did not receive a special education unit (n=52). Four subjects in the experimental group, however, withdrew prior to completing the study because of schedule conflicts. Each subject reviewed and signed an institutionally approved consent form prior to participating in the study.

Test Instrument

The State University of New York at Buffalo School of Nursing AIDS Study Questionnaire modified for a physical therapy population included a 79-item pretest instrument and a 77-item posttest instrument. Modifications included updating knowledge items to reflect current terminology, substituting "physical therapists" for "nurses" in attitude items, and adding items concerning willingness to treat patients with AIDS. The pretest instrument consisted of 10 items on the subjects' demographic characteristics, 34 items on knowledge about AIDS, 30 Likert scale items on attitudes toward caring for patients with AIDS, and 5 Likert scale items depicting clinical situations in which the subjects were asked to respond on their willingness to treat the patients described. Because it was beyond the scope of this study to observe the clinical behavior of the students, the final section of items concerning intent to treat patients who have AIDS was included in an attempt to measure possible behavioral change attributable to the educational intervention. The posttest instrument consisted of an alternate form of the pretest instrument without duplication of the demographic information.

Validity and reliability of measurements obtained with the test instrument were established prior to its use in the study. Face validity and content validity were established by objective evaluation of the test by physicians, AIDS experts, physical therapists, and physical therapy students at a separate institution. This evaluation was conducted via questionnaire and consisted of assessment of instrument structure, wording, ability to understand questions, content, clarity, question correctness, and completeness. The responses to the questionnaire yielded an excellent rating for this instrument. To determine test-retest reliability, a correlation coefficient was calculated for each of the three sections concerning knowledge, attitudes, and willingness to treat patients who have AIDS. This assessment was completed using a similar subject group (entry-level undergraduate junior physical therapy students) at a similar institution. To match the study procedure, a 1-week interval between pretest and posttest was used to establish test-retest reliability. Pearson Product-Moment Correlation Coefficients of .934 (section 2--knowledge about AIDS), .823 (section 3--attitudes toward patients with AIDS), and .800 (section 4--willingness to treat patients who have AIDS) indicate good to excellent reliability of the test measurements.

Education Unit

The single 4-hour educational unit consisted of two major content areas. In part 1, information was presented on the human immune system; the AIDS virus (HIV); the effects of HIV infection on the immune system; AIDS epidemiology; immunopathology; manifestations and complications; modes of HIV infection; medical and physical therapy treatment regimens for the management of HIV infection and the secondary infections, cancers, and neurological disease patients with AIDS present; and methods of universal precautions and isolation techniques. Part 2 addressed feelings associated with being a patient with AIDS and identified negative attitudes directed toward patients with AIDS, members of high-risk groups, or persons close or related to patients with AIDS. After feelings associated with being a patient with AIDS were identified, possible sources of these feelings were discussed, and the American Physical Therapy Association's Code of Ethics[22] was presented to assist subjects in resolution of negative attitudes and to increase their willingness to treat and interact with these groups.

The education unit was pilot tested by a group of physical therapists and physical therapy students prior to its implementation for the study. The results of an objective evaluation and exit interview indicated an excellent rating of the education unit for use with physical therapy students and validated its use for this study. The objective evaluation, consisting of assessment of education unit presenter, written and audiovisual material, organization and accuracy of content, and clinical relevance to physical therapy, was conducted via questionnaire.

Procedure

The effects of an AIDS education program on physical therapy students' knowledge, attitudes, and willingness to treat patients who have AIDS were determined via a two-group pretest-posttest delayed-intervention experimental design. Following random group assignment and completion of consent forms, both groups completed the pretest. Several days later, the experimental group attended the AIDS education unit. One week after the pretest, the experimental group and the control group completed the posttest. The following week, the control group received the delayed-intervention AIDS education unit. Each testing session was completed in 45 minutes, and the education unit was completed in a single 4-hour seminar.

Data Analysis

The numerical data gathered via the pretest and posttest instruments were entered and analyzed via the SPSS/PC software program.(*)The pretest-posttest results of both groups were analyzed for descriptive information by item analysis via frequencies and means. Total section (sections 2-4) scores were analyzed via means, standard deviations, and difference means with standard deviations for each group. Independent t tests were used to test for initial comparability of groups at pretesting. To test the research hypothesis, a one-way, repeated-measures multivariate analysis of variance (MANOVA)[23-25] design was used to determine differences over time between the groups. Paired t tests were used individually for each group to determine whether each group individually changed significantly over time.

Correct responses on section 2 items regarding AIDS knowledge were totaled for each group at the pretest and the posttest. Likert scale items in section 3 concerning subjects' attitudes toward patients with AIDS were worded negatively; therefore, the lower the subjects' total scores, the more negative their attitudes were toward patients with AIDS. These items were totaled and presented as a mean total score and a mean Likert scale score for each group at each testing session. Likert scale items in section 4 concerning subjects' willingness to treat patients who have AIDS were worded positively; therefore, the lower the subjects' total scores, the more willing they were to treat patients who have AIDS. These items were also totaled and are presented as a mean total score and a mean Likert scale score for each group at each testing session. Likert scale scores were determined by dividing the total score by the number of items in each section.

Results

Tables 1 through 3 show each group's mean pretest and posttest scores, mean difference score, and corresponding standard deviations. In order to ensure comparability of groups at pretest, independent t tests of group differences on pretest were performed and showed no significant difference between groups at pretesting on any of the measurements collected (P>.05). At pretest, correct responses on knowledge about AIDS ranged from 11 to 30 (X [bar] =21.38, SD=3.88) for the experimental group and from 12 to 31 (X [bar] =20.85, SD=4.08) for the control group. Posttest scores ranged from 21 to 33 (X [bar] =28.89, SD=2.46) for the experimental group and from 12 to 32 (X [bar] =21.00, SD=4.39) for the control group. Total section scores on attitudes toward patients with AIDS at pretest ranged from 74 to 159 (X [bar] =116.68, SD=18.89) for the experimental group and from 61 to 168 (X [bar] =121.21, SD=20.18) for the control group. Posttest scores ranged from 86 to 154 (X [bar] =123.32, SD=16.69) for the experimental group and from 63 to 173 (X [bar] =117.96, SD=19.22) for the control group. Converted Likert scale scores are given in Table 2. At pretest, total section scores on willingness to treat patients ranged from 5 to 20 (X [bar] =11.47, SD=3.46) for the experimental group and from 5 to 20 ([X [bar] =11.29, SD=3.74) for the control group. Posttest scores ranged from 5 to 18 (X [bar] =10.08, SD=2.84) for the experimental group and from 5 to 20 (X [bar] =11.42, SD=3.26) for the control group. Converted Likert scale scores are given in Table 3.

Visual examination of the data suggested a change in the desired direction for the experimental group, and no change or a change in the nondesired direction for the control group from pretest to posttest. To determine whether the data supported the research hypothesis, that is, were there differences over time between experimental and control groups attributable to the AIDS education unit, a one-way, repeated-measures MMOVA design[23-25] was used to statistically analyze the data. The MANOVA results showed significant intervention effects for each of the sections (AIDS knowledge: F=104.48, P<.0001; attitudes toward patients with AIDS: F=27.34, P<.0001; and willingness to treat patients who have AIDS: F=7.75, P=.006).

In order to clarify the nature or pattern of the differences between the groups over time, paired t tests were performed for each group separately on each of the measures. The results of these individual group paired t tests are presented in Tables 1 through 3. An examination of these tables reveals that the experimental group experienced a significant change in the desired direction on each section P<.05). The control group, however, showed no significant change on AIDS knowledge or on willingness to treat patients who have AIDS (P>.05) and a significant change in the nondesired direction in their attitudes toward patients with AIDS (P<.05).

To better examine the key areas in which the subjects changed, Tables 4 through 6 present specific pretest and posttest item responses for each group. Items were chosen that best represent the areas examined on the test instrument and that best reflect each group's score on all items in that area.

Table 4. Percentage of Experimental and Control Group Subjects Answering
Section 2 (Knowledge About AIDS(a)) Items Correctly at Pretest and Posttest(b)
item Topic                    Group          Posttest   Posttest
AIDS immunopathology           Experimental   14.9        93.6
                               Control        15.4        13.5
Modes of HIV(c) transmission   Experimental   46.8       100.0
                               Control        61.5        61.5
Disease etiology               Experimental   31.9        55.3
                               Control        23.1        23.1
Risk groups                    Experimental   95.7       100.0
                               Control        84.6        88.5
Universal precautions          Experimental   44.7        93.6
                               Control        38.5        38.5
Physical therapy training      Experimental   83.0        95.7
                               Control        75.0        69.2
(a) Aids=acquired immunodeficiency syndrome.
(b) Percentage indicated for 6 of 34 total section items.
(c) HIV=human immunodeficiency virus.

[TABULAR DATA 5 & 6 OMITTED]

At the pretest, items related to AIDS immunopathology, HIV etiology, and universal precautions were answered correctly by 14.9%, 31.9%, and 44.7% of the experimental group, respectively, and by 15.4%, 23. 1%, and 38.5% of the control group, respectively. At the posttest, 93.6%, 55.3%, and 93.6% of the experimental group, respectively, answered these items correctly, whereas 13.5%, 23. 1%, and 38.5% of the control group, respectively, had correct responses. Additional areas of knowledge examined on the test related to modes of HIV transmission, risk groups, and physical therapists training to treat patients who have AIDS. At the pretest, the experimental group correctly answered 46.8%, 95.7%, and 83.0% of these items, respectively, and the control group correctly answered 61.5%, 84.6%, and 75.0% of these items, respectively. At the posttest, 100.0%, 100.0%, and 95.7% of the experimental group, respectively, had correct responses, and 61.5%, 88.5%, and 69.2% of the control group, respectively, answered these items correctly (Tab. 4).

At the pretest, both groups were similar in their attitudes toward patients with AIDS. Mean responses to items regarding feelings toward homosexuals, intravenous drug users, and persons with hemophilia; right to refuse care to patients with AIDS; fear of transmitting HIV to significant others; and preparation to meet the needs of patients with AIDS ranged from 2.04 to 3.69, indicating negative to undecided attitudes on these issues. At the posttest, the experimental group's responses to these items ranged from 2.94 to 3.92, indicating an overall shift toward more positive attitudes regarding these issues. The control group's attitudes remained negative to undecided (2.19-3.60). Both groups maintained some degree, of fear of contracting HIV (experimental group: pretest=2.55, posttest=2.43; control group: pretest= 2.74, posttest=2.62) and consistently disagreed with the item concerning not treating a patient who has AIDS because of the hopelessness of the prognosis (experimental group: pretest-posttest=4.19, control group: pretest-posttest=4.21) (Tab. 5).

At the time of the pretest, both groups were somewhat willing to treat the patients in the examples. The mean pretest scores (experimental group: 1.96-2.60; control group: 2.00-2.46) indicated some agreement toward treating these patients with the techniques described, although subjects were less willing to treat when the methods included chest physical therapy or wound management (experimental group: 2.13-2.60; control group: 2.12-2.46). At the posttest, the experimental group had lower mean scores on every item in this section (1.92-2.15), indicating an increased willingness to treat the patients in the examples using the treatment methods given. The control group's mean posttest scores remained essentially unchanged from the pretest scores (2.04-2.58), indicating no significant change in this group's willingness to treat patients who have AIDS (Tab. 6).

Discussion

This study was undertaken to determine (1) entry-level undergraduate physical therapy students' level of AIDS knowledge, attitudes toward patients with AIDS, and willingness to treat patients who have AIDS and (2) the effect of an AIDS education unit on these variables. The reported results confirm the lack of preparation of entry-level undergraduate physical therapy students to treat patients who have AIDS and support the hypothesis that the AIDS education unit had a positive effect on the three variables studied.

Results of the data analysis support all components of the research hypothesis. The results of the MANOVA and the t-test analysis showed that the experimental group and the control group changed in significantly different ways from each other from pretest to posttest. These results also revealed that the experimental group had significant improvement in all components, whereas the control group showed no change or scored lower on all components. The MANOVA results indicate the intervention had a significant effect on the experimental group subjects' knowledge about AIDS, attitudes toward patients with AIDS, and willingness to treat patients who have AIDS.

Although both groups reported a willingness to treat patients who have AIDS, examination of key item responses confirmed the lack of AIDS knowledge and negative attitudes of both groups at the time of the pretest. At the time of the posttest, only the experimental group subjects (ie, those who received the education unit prior to the posttest) showed significant improvement on items in all three areas studied.

Table 4 presents the percentages of subjects in both groups answering section 2 (AIDS knowledge) items correctly at the time of the pretest and the posttest. The experimental group subjects showed an improvement in their knowledge of AIDS immunopathology, HIV modes of transmission, AIDS etiology, risk groups, use of universal precautions, and physical therapists' role in the care of patients with AIDS. The control group subjects showed little or no change in their knowledge of these areas.

Table 5 presents group mean scores on section 3 (attitudes toward patients with AIDS) items at the time of the pretest and the posttest. The more the subjects disagreed with the negatively worded items in this section, the more positive their attitudes were toward patients with AIDS, which would be reflected in a higher mean score. Again, the experimental group subjects showed an improvement in their attitudes toward various types of patients with AIDS, right to refuse care, fear of transmitting HIV to significant others, and preparation to meet the needs of patients with AIDS. The control group subjects displayed little change or a change to more negative attitudes. Their responses indicated that all subjects continued to have a fear of contracting HIV infection, and all subjects displayed a consistent feeling of disagreement about not treating patients who have AIDS because of the hopelessness of the prognosis.

As a result of the pretest, both groups identified the many possible causes of fear and negative attitudes toward patients with AIDS. Whereas the experimental group received the intervention, the lack of immediate intervention, attitude resolution, and pretest-posttest time span may have contributed to the shift of the control group to significantly more negative attitudes toward patients with AIDS. Although both groups reported a continued fear of contracting the HIV infection at the time of the posttest, the experimental group reported a significantly increased willingness to treat patients who have AIDS, whereas the control group did not report such willingness. Thus, the intervention enabled these subjects to be more willing to treat patients who have AIDS despite a possibly natural fear of the contagion.

Last, Table 6 presents group mean scores on section 4 (willingness to treat patients who have AIDS) items at the time of the pretest and the posttest. The more the subjects agreed with the positively worded items in this section, the more willing they were to treat patients who have AIDS, which would be reflected in a lower mean score. Although all subjects were fairly willing to treat patients who have AIDS, the experimental group's responses showed an increased willingness at the posttest, and the control group showed little or no change in the desired direction.

This study's findings parallel those found in reports of research done with physicians, dentists, nurses, paramedical staff, and medical and nursing students. Physical therapy students, like other health care professionals, lack the appropriate knowledge about AIDS and possess negative attitudes toward patients with AIDS, therefore contributing to an unwillingness to treat these patients. Education about AIDS, which included knowledge-based information and addressed attitudinal issues, had a positive impact on subjects' AIDs knowledge, their attitudes toward patients with AIDS, and their willingness to treat patients who have AIDS. Education must be discipline specific so as to best address the particular needs and concerns of each professional providing care.

This study was limited to entry-level undergraduate physical therapy students at one institution; therefore, it is not representative of all physical therapy students. The groups also could not be isolated from each other during the study. Finally, because of the inability to measure clinical behavior, a true determination of how subjects will treat patients who have AIDS cannot be made. The results, however, support the observations in the literature regarding other health professionals and indicate that both physical therapists and physical therapy students are not well prepared to treat patients who have AIDS and therefore are in need of appropriate discipline-specific AIDS education. Section 4 of the test instrument was designed to determine intent to behave or willingness to treat the AIDS patients in the examples given. The subjects were given case studies with physical therapy referrals and asked to respond by indicating their willingness to treat these patients,

Based on the findings of this study, follow-up research is needed. Further study of other levels of physical therapy students and physical therapists, measurement of actual practice behaviors, and comparisons of different educational interventions are needed.

During the course of this study, several events occurred that further supported the implementation of a formal AIDS education program for physical therapy students and physical therapists. First, many of the clinical facilities that students of this institution affiliate with have begun to require students to have AIDS education prior to completing their clinical internships. Second, various health facilities nationwide now require that all employees receive AIDS education. Third, the licensing departments of some states (eg, Washington, Florida) are now requiring health care professionals, including physical therapists, to complete a specified number of hours of AIDS education in order to become licensed. The agencies requiring this education have also set guidelines for curriculum content.

The results of this study showed a planned AIDS education unit geared specifically toward physical therapists improved subjects' knowledge, attitudes, and willingness to treat patients who have AIDS. The curriculum guidelines set by the agencies requiring AIDS education were all met in the education unit designed and implemented in this study. This institution will therefore be expanding and incorporating this AIDS education unit into the curriculum for all physical therapy students.

Following several implementations of the AIDS education program, two revisions of the program were made. First, to facilitate better comprehension of a great deal of information and enable more time for case studies, two 3-hour sessions with a 1-hour refresher course are being used for program implementation. Second, more time is allotted to address attitudinal and ethical issues with the addition of a second attitudinal exercise discussion. All other portions of the education program were addressed appropriately and meet the curriculum guidelines of agencies and states requiring AIDS education.

Conclusions

Several conclusions are made based on the findings of this study. First, before implementation of the education unit, entry-level undergraduate physical therapy students at this institution were found to lack knowledge about AIDS, possess negative attitudes toward patients with AIDS, and be somewhat willing to treat patients who have AIDS. Second, education on AIDS addressing knowledge-based information and attitudinal issues is needed for the physical therapy students in this study. Third, a planned AIDS education program significantly improved the AIDS knowledge, the attitudes toward patients with AIDS, and the willingness to treat patients who have AIDS of the entry-level undergraduate physical therapy students studied. (*) SPSS Inc, 444 N Michigan Ave, Chicago, IL 60611

Acknowledgments

Special thanks are extended to Susan Bennett, EdD, PT, Richard Johnston, PT, and Joan Gunther, PhD, PT, for their help in reviewing this project and to Roger Fiedler, PhD, for statistical assistance.

References

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