Archives of Physical Medicine and Rehabilitation
Volume 89, Issue 1 , Pages 105-113, January 2008

Rehabilitation Professionals and Human Immunodeficiency Virus Care: Results of a National Canadian Survey

Presented in part to AIDS Impact 2005, April 4−7, 2005, Cape Town, South Africa; the Canadian Association of HIV Research, May 12−15, 2005, Vancouver, BC, Canada; and the Council on Social Work Education, February 16−19, 2006, Chicago, IL.

  • Catherine Worthington, PhD

      Affiliations

    • Faculty of Social Work, University of Calgary, Calgary, AB, Canada
    • HIV Social, Behavioural and Epidemiological Studies Unit, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
    • Corresponding Author InformationReprint requests to Catherine Worthington, PhD, Faculty of Social Work, University of Calgary, 2500 University Dr NW, Calgary, AB T2N 1N4, Canada
    • ,
  • Ted Myers, PhD

      Affiliations

    • HIV Social, Behavioural and Epidemiological Studies Unit, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
    • Public Health Sciences, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
    • ,
  • Kelly O’Brien, BScPT

      Affiliations

    • HIV Social, Behavioural and Epidemiological Studies Unit, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
    • Department of Physical Therapy, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
    • Department of Health Policy, Management and Evaluation, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
    • ,
  • Stephanie Nixon, PhD

      Affiliations

    • Public Health Sciences, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
    • Department of Physical Therapy, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
    • Health Economics and HIV/AIDS Research Division, University of KwaZulu-Natal, Durban, South Africa.
    • ,
  • Rhonda Cockerill, PhD

      Affiliations

    • HIV Social, Behavioural and Epidemiological Studies Unit, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
    • Department of Health Policy, Management and Evaluation, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
    • ,
  • Tarik Bereket, MA

      Affiliations

    • HIV Social, Behavioural and Epidemiological Studies Unit, Faculty of Medicine, University of Toronto, Toronto, ON, Canada

Article Outline

Abstract 

Worthington C, Myers T, O’Brien K, Nixon S, Cockerill R, Bereket T. Rehabilitation professionals and human immunodeficiency virus care: results of a national Canadian survey.

Objective

To describe rehabilitation professionals’ practices, knowledge and training, professional views, and service delivery issues for people living with human immunodeficiency virus (HIV) or acquired immune deficiency syndrome (PHAs) in Canada.

Design

Nationwide cross-sectional postal survey.

Setting

Canada.

Participants

Random sample (N=2105) of occupational therapists, physical therapists, speech-language pathologists, and physiatrists who had practiced in the past year.

Interventions

Not applicable.

Main Outcome Measures

Survey items on current practices, HIV knowledge and training, professional views on rehabilitation and HIV, and HIV rehabilitation service delivery issues.

Results

Seventy-four percent (1492/2006) of the traceable sample responded, 53% (n=1058) of whom yielded completed surveys. Sixty-one percent of survey respondents never knowingly had served an HIV-positive patient. Of this group, 27% indicated these were patients they would like to work with, 27% indicated they were unwilling, and 46% were unsure. The 39% who knowingly had served PHAs had served an average of 4 PHAs in the last year, and less than 25% of their HIV patients’ rehabilitation issues were HIV-related.

Conclusions

Despite the role rehabilitation professionals have to play in the care of PHAs, only a minority serves PHAs. Results of this survey show a potential gap between the documented rehabilitative needs of PHAs and services provided by the rehabilitation professional community.

Key Words: Acquired immunodeficiency syndrome, Health care surveys, HIV, Rehabilitation

 

SINCE THE INTRODUCTION of new medications (highly active antiretroviral therapy [HAART]) in 1996, people living with human immunodeficiency virus (HIV) or acquired immune deficiency syndrome (AIDS) (PHAs) who are able to access and tolerate HAART live longer.1 At the end of 2002, an estimated 56,000 people were living with HIV in Canada, an approximate 12% increase from 49,800 in 1999.2 Although the incidence has remained stable, with an estimated 2800 to 5200 new infections in 2002, the prevalence of HIV is increasing in Canada.2 In the United States, an estimated 1,039,000 people were living with HIV at the end of 2003, 24% to 27% of whom were unaware of their status.3 As a result, many health care providers may be serving PHAs, both those who are aware and unaware of their HIV status, and thus need to understand the disease to recognize it and provide appropriate patient care and referrals.

As the course of HIV has changed, rehabilitation needs of PHAs have increased and become more complex. These people may face a variety of day-to-day health-related consequences and adverse effects of associated treatments. A study conducted in the United States found that asymptomatic and symptomatic PHAs experienced higher levels of perceived physical disability compared with the general population.4 A survey conducted in British Columbia, Canada, documented that 80% of those surveyed experienced at least 1 impairment, activity limitation, or participation restriction attributed to their HIV status within the last month.5 This increased disablement highlights an important role for rehabilitation in HIV care.

Despite the prevalence of disability among PHAs, traditional rehabilitation professions including physical therapy (PT), physiatry, occupational therapy (OT), and speech-language pathology (SLP) are largely absent in the field of HIV clinical practice and research. With the exception of the small amount of evidence that documents physical disablement5, 6, 7, 8 and limitations in role function,5, 9, 10 relatively little research focuses on rehabilitation in HIV care. Furthermore, despite suggestions on how to approach rehabilitation practice in the context of HIV,11, 12 little research has determined whether the health care community is prepared to address the increased disablement needs of PHAs. The purpose of this study was to inform HIV education and clinical practice by describing rehabilitation professionals’ current practices, knowledge and training, professional views, and service delivery issues in the provision of services to PHAs in Canada.

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Methods 

Study Design 

We conducted a nationwide cross-sectional postal survey with a random sample of rehabilitation professionals in Canada using the Dillman tailored design method.13 This study protocol was approved by the University of Toronto HIV/AIDS Research Ethics Board. A national advisory committee, consisting of PHAs, rehabilitation professionals with experience in HIV, and representatives from regulatory bodies and HIV organizations, was consulted through all phases of the study.

Survey Development 

The HIV/AIDS Rehabilitation Conceptual Framework was developed to guide survey construction.14 Using the International Classification of Functioning, Disability and Health,15 “rehabilitation” was broadly defined as all services and activities that address or prevent impairments, activity limitations, or social participation restrictions experienced by a person.14

Survey Instrument 

The survey instrument included sections on (1) current clinical rehabilitation practice and service provision issues, (2) types of patients served, (3) HIV and AIDS knowledge and training, (4) views on the roles of health providers in rehabilitation in the context of HIV and AIDS, (5) current and future rehabilitation service delivery issues in the context of HIV and AIDS, and (6) personal information (including age and sex). Preliminary survey instruments were pretested and refined with advisory committee members and translated into French. The mailing procedure was pilot-tested with 5 rehabilitation professionals. (A copy of the survey instrument is available on request.)

Target Sample 

Although the HIV/AIDS Rehabilitation Conceptual Framework identified multiple stakeholders who play a role in rehabilitation for PHAs, we focused on the traditionally defined rehabilitation professionals, including occupational therapists, physiatrists, physical therapists, and speech-language pathologists who had practiced clinically within the past year and who may or may not have worked in the area of HIV and AIDS. In a parallel study, we also surveyed the known population of HIV specialists, including dieticians, nurses, pharmacists, physicians, psychologists, and social workers.16, 17

Sampling Frame 

A random sample (N=2105) was drawn from national rehabilitation professional association lists. To create the most complete and representative sampling frame possible, these lists were cross-checked and supplemented with available provincial or territorial regulatory body lists. This cross-checking increased the total rehabilitation pool from which to draw the random sample by over 30% (37% occupational therapists, 24% physical therapists, 36% speech-language pathologists). For physiatrists, a random sample was drawn from a regulatory body list.

Survey Implementation 

In compliance with the Dillman13 tailored design method, the mailouts included (1) a notice letter mailed approximately 1 week before the survey package; (2) the survey package, including questionnaire, cover letter, refusal card, and a self-addressed prepaid return envelope; (3) a thank you and reminder postcard mailed 1 to 2 weeks after the survey, and for those that did not respond; and (4) a second survey package mailed 2 to 4 weeks after the first mailing. Materials were distributed in French and English to Quebec and New Brunswick and in English to the other provinces and territories.

Data Analysis 

Descriptive statistics were used to summarize results. Multinomial logit and logit regression models were constructed to examine predictors (including demographic and practice characteristics; training, knowledge and awareness; and views on HIV and AIDS rehabilitation) of serving PHAs and of willingness to serve PHAs among those who had never knowingly served these patients. Because a high percentage of respondents indicated “do not know” for several items, these were included as dummy (indicator) variables to capture the full range of opinion or experience.

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Results 

Response 

Of the 2105 rehabilitation professional surveys mailed, 99 (5%) could not be delivered (returned to sender with no tracing possible). Of the 2006 remaining mailings, 1492 (74%) responses were received; 198 (10%) respondents were ineligible to participate (no clinical practice within the past year), 236 (12%) refused to participate, and 1058 (53%) completed the survey. Of those who completed the survey, 47% were physical therapists, 41% were occupational therapists, 9% were speech-language pathologists, and 3% were physiatrists. These response rates were roughly proportionate to the size of each profession surveyed.

Description of Survey Respondents 

Respondent characteristics are displayed in table 1. Survey respondents had practiced an average ± standard deviation (SD) of 14±10 years and were engaged in a combination of activities including clinical care, research, education, administration, policy work, and health promotion.

Table 1. Characteristics of Survey Respondents (n=1058)
Characteristicsn⁎%
Profession
PT50047
OT43241
SLP969
Physiatry303
Sex
Female91388
Male12612
Age (y)
<2510<1
25−3543442
36−5043041
>5016416
Community size
Metropolitan (>500,000)44843
Urban (100,000−500,000)32731
Rural (<100,000)26726
Region
Ontario56353
Alberta14013
British Columbia11110
Prairies (Saskatchewan, Manitoba)10510
Atlantic Canada (NB, Newfoundland, NS, PEI)989
Quebec353
NWT, Yukon, Nunavut6<1
Northern region808
Work setting (categories not mutually exclusive)
Patient’s home/home care30629
Hospital: inpatient30629
Hospital: outpatient23022
Private practice: individual23422
Private practice: group19719

Abbreviations: NB, New Brunswick; NS, Nova Scotia; NWT, Northwest Territories; PEI, Prince Edward Island.

⁎n varies by question due to item nonresponse.

Current Practices in HIV Rehabilitation 

Sixty-one percent of respondents reported that they had never knowingly served an HIV-positive patient. Those who had not knowingly served a patient who was HIV positive were asked, “Is this a client group you personally would like to work with?” We deliberately forced respondents to choose 1 of 3 responses to better understand their comfort levels with PHA treatment independent of organizational factors and referrals. Of this group, 27% indicated they would not want to work with this patient group (unwilling), 46% were unsure, and 27% indicated this was a patient group they would like to work with (willing). The multinomial logit regression model (model χ2=162.2, P<.001, pseudo R2=15%) indicated that compared with those who indicated they would like to work with PHAs (willing), those who said they were unwilling were more likely to have practiced longer, more likely to believe that their profession was not as important (and less likely to say they “don’t know” whether their profession was important) for the treatment of PHAs, and more likely to agree that many rehabilitation professionals are uncomfortable (or not know whether rehabilitation professionals are uncomfortable) with the idea of working with PHAs. Those who said they were unsure whether they would like to work with PHAs (compared with those who were willing) were less likely to work in rural areas than urban areas, less likely to have received specialty training or continuing education in HIV and AIDS rehabilitation in the last 5 years, and more likely to agree that many rehabilitation professionals are uncomfortable with the idea of working with PHAs (table 2).

Table 2. Multinomial Logit Regression Predicting Rehabilitation Professionals’ Degree of Willingness to Serve PHAs (n=631 rehabilitation professionals who had not knowingly served PHAs in the past year)
Rehabilitation Professionals’ CharacteristicsUnwilling (vs Willing) RRR (95% CI)Unsure (vs Willing) RRR (95% CI)
Practice characteristics
Geographic area
Urban1.01.0
Rural0.7(0.4−1.8)0.5(0.3−0.9)⁎
Metropolitan1.0(0.5−2.0)0.8(0.4−1.4)
No. of patients
Log(patients)1.2(0.9−1.4)1.1(0.9−1.3)
Time in practice
Years in profession1.1(1.0−1.1)⁎1.0(0.9−1.0)
Training, knowledge, and awareness
HIV/AIDS training as part of health professional degree
Had training/unsure1.01.0
Did not have training1.7(0.7−2.6)1.3(0.7−2.3)
Specialty training/continuing education in HIV/AIDS rehabilitation in last 5y
Did not participate/don’t know1.01.0
Participated0.4(0.1−1.1)0.4(0.2−0.9)⁎
Reported HIV knowledge
Sum of reported knowledge levels in 10 areas of HIV (min, 10; max, 30)1.0(0.9−1.1)1.0(0.9−1.1)
HIV awareness in workplace
Degree of HIV awareness (0−4)§0.9(0.6−1.3)1.3(0.9−1.8)
Opinion on how important the profession is for the treatment of PHAs
Scale of 1−3∥0.5(0.3−0.9)†0.7(0.5−1.2)
Did not know0.2(0.0−0.8)⁎1.4(0.4−5.7)
Views on HIV/AIDS rehabilitation
Rehabilitation professionals currently possess adequate knowledge and skills to assess and treat PHAs
Scale of 1−4‡1.6(0.8−2.1)1.1(0.7−1.6)
Did not know1.1(0.3−3.9)0.7(0.2−2.0)
Rehabilitation professionals who provide services for PHAs need specialized training in the area of HIV/AIDS
Scale of 1−4‡1.0(0.7−1.4)1.1(0.7−1.4)
Did not know0.3(0.0−5.0)1.1(0.2−7.0)
Working with PHAs is similar to working with people with other chronic illnesses
Scale of 1−4‡0.8(0.5−1.2)1.0(0.7−1.4)
Did not know0.9(0.2−3.6)1.6(0.5−5.3)
Many rehabilitation professionals are uncomfortable with the idea of working with PHAs
Scale of 1−4‡2.7(1.6−4.5)†1.6(1.1−2.5)⁎
Did not know7.3(1.5−35.8)†2.2(0.6−8.3)
Rehabilitation services are primarily needed for PHAs at palliative stages of illness
Scale of 1−4‡0.9(0.6−1.5)1.0(0.6−1.5)
Did not know0.8(0.2−2.6)0.8(0.3−2.2)
Serving PHAs is more demanding than serving patients with other chronic illnesses or conditions
Scale of 1−4‡1.0(0.5−1.7)1.1(0.7−1.8)
Did not know1.4(0.3−5.7)2.3(0.7−8.2)
Community-based agencies such as AIDS service organizations have a large role in rehabilitation in the context of HIV/AIDS
Scale of 1−4‡0.9(0.5−1.5)0.8(0.5−1.3)
Did not know0.7(0.1−4.5)0.3(0.1−1.7)
Rehabilitation for PHAs should be a larger priority
Scale of 1−4‡1.0(0.5−1.9)0.7(0.4−1.1)
Did not know1.8(0.3−11.9)0.7(0.1−3.3)

NOTE. Model controls for sex, survey language (English or French), age group, profession (OT, PT, SLP, physiatry), and province or territory.

Abbreviations: CI, confidence interval; RRR, relative risk ratio.

⁎Significant at P≤.05.

†Significant at P≤.01.

‡Scale range: 1 (strongly disagree), 2 (disagree), 3 (agree), 4 (strongly agree).

§Scale range: 0 (no awareness at all), 1 (little awareness), 2 (some awareness), 3 (high awareness), 4 (very high awareness).

∥Scale range: 1 (not at all important), 2 (somewhat important), 3 (very important).

Rehabilitation Professionals Who Serve PHAs 

The 39% of rehabilitation professionals who had knowingly served PHAs had served an average of 4 HIV-positive patients (range, 1−240 patients) in the past year. Almost all of these rehabilitation professionals (98%) stated that less than 25% of their current rehabilitation caseload was HIV-related, and 75% indicated that less than 25% of the rehabilitation issues their HIV patients presented with were HIV-related.

Logit regression modeling (model χ2=181.15, P<.001, pseudo R2=16%) indicated that having knowingly served an HIV-positive patient was positively associated with higher reported HIV knowledge, receipt of specialty training or continuing education in HIV and AIDS rehabilitation in the last 5 years, working in a metropolitan area (compared with an urban area), serving a higher number of patients in the past year, profession (being an occupational therapist, physical therapist, or physiatrist compared with speech-language pathologist), practicing in particular provinces (British Columbia and Atlantic provinces [Nova Scotia, Prince Edward Island] compared with Ontario), and negatively associated with feeling that serving PHAs is more demanding (or not knowing whether serving PHAs is more demanding) than serving patients with other chronic illnesses or conditions (table 3).

Table 3. Logit Regression Predicting Having Knowingly Served a PHA (n=1058)
Rehabilitation Professionals’ CharacteristicsKnowingly Served a PHA, OR (95% CI)
Practice characteristics
Geographic area
Urban1.0
Rural0.7(0.4−1.1)
Metropolitan1.7(1.1−2.5)⁎
No. of patients
Log(patients)1.1(1.0−1.3)⁎
Time in practice
Years in profession1.0(1.0−1.0)
Profession
SLP1.0
OT2.5(1.2−5.6)⁎
PT2.4(1.1−5.3)⁎
Physiatrist11.5(3.0−43.3)†
Province
Ontario1.0
British Columbia2.0(1.2−3.5)†
Alberta1.1(0.7−1.8)
Saskatchewan1.5(0.7−3.1)
Manitoba0.9(0.4−2.0)
Quebec1.1(0.3−4.3)
Newfoundland1.1(0.4−3.1)
Nova Scotia/Prince Edward Island2.3(1.1−4.9)⁎
New Brunswick1.5(0.4−5.1)
Training, knowledge and awareness
HIV/AIDS training as part of health professional degree
Had training/unsure1.0
Did not have training0.7(0.5−1.0)
Specialty training/continuing education in HIV/AIDS rehabilitation in last 5y
Did not participate/don’t know1.0
Participated2.2(1.3−3.8)†
Reported HIV knowledge
Sum of reported knowledge levels in 10 areas of HIV (min, 10; max, 30)1.1(1.0−1.1)⁎
HIV awareness in workplace
Degree of HIV awareness (0−4)§1.2(0.9−1.5)
Opinion on how important the profession is for the treatment of PHAs
Scale of 1−3∥1.3(0.9−1.8)
Did not know1.2(0.5−3.3)
Views on HIV/AIDS rehabilitation
Rehabilitation professionals currently possess adequate knowledge and skills to assess and treat PHAs
Scale of 1−4‡1.0(0.8−1.3)
Did not know1.0(0.5−2.2)
Rehabilitation professionals who provide services for PHAs need specialized training in the area of HIV/AIDS
Scale of 1−4‡0.8(0.7−1.0)
Did not know0.8(0.2−3.4)
Working with PHAs is similar to working with people with other chronic illnesses
Scale of 1–4‡0.9(0.7−1.2)
Did not know0.6(0.2−1.3)
Many rehabilitation professionals are uncomfortable with the idea of working with PHAs
Scale of 1−4‡0.8(0.6−1.1)
Did not know0.5(0.2−1.2)
Rehabilitation services are primarily needed for PHAs at palliative stages of illness
Scale of 1−4‡1.2(0.9−1.6)
Did not know1.3(0.6−2.9)
Serving PHAs is more demanding than serving patients with other chronic illnesses or conditions
Scale of 1−4‡0.7(0.5−0.9)⁎
Did not know0.2(0.1−0.6)†
Community-based agencies such as AIDS service organizations have a large role in rehabilitation in the context of HIV/AIDS
Scale of 1−4‡0.9(0.7−1.3)
Did not know0.8(0.2−2.4)
Rehabilitation for PHAs should be a larger priority
Scale of 1−4‡0.9(0.7−1.3)
Did not know0.9(0.3−2.6)

NOTE. Model controls for: sex, survey language (English or French), and age group.

Abbreviation: OR, odds ratio.

⁎Significant at P≤.05.

†Significant at P≤.01.

‡Scale range: 1 (strongly disagree), 2 (disagree), 3 (agree), 4 (strongly agree).

§Scale range: 0 (no awareness at all), 1 (little awareness), 2 (some awareness), 3 (high awareness), 4 (very high awareness).

∥Scale range: 1 (not at all important), 2 (somewhat important), 3 (very important).

Referrals, Presenting Disablement of PHAs, and Treatment Interventions 

The majority of referrals to rehabilitation for PHAs were received from physicians (81%) (including general practitioners, infectious disease specialists, neurologists, orthopedic surgeons, general internists, and psychiatrists). HIV patients presented to rehabilitation professionals with a range of disablement (fig 1). Consistent with the types of disablement presenting at assessment, the treatment interventions used primarily addressed impairments and activity limitations experienced by PHAs (fig 2).

  • View full-size image.
  • Fig 1. 

    Percentage of rehabilitation professionals serving PHAs with patients who presented with the presented impairments, activity limitations, and participation restrictions during assessment within the past year (n=219).

  • View full-size image.
  • Fig 2. 

    Percentage of rehabilitation professionals using the presented treatment interventions to address impairments, activity limitations, and participation restrictions of HIV patients within the past year (n=218).

Rehabilitation Professionals’ HIV and AIDS Knowledge and Training 

Knowledge 

A substantial percentage of respondents rated themselves as “not at all knowledgeable” in areas of HIV-related policies (79%), treatment medications for HIV (69%), the episodic course of HIV infection (68%), HIV pathogenesis (59%), HIV epidemiology (52%), psychosocial aspects of HIV (34%), HIV-associated disability (33%), and the diagnosis of HIV infection (32%).

Training 

Twenty-seven percent of respondents stated that they had received any training in HIV and AIDS as part of their professional health degrees. The mean total number of hours of education in HIV and AIDS was 12 (range, 0−435h). Only 11% of respondents participated in specialty training or continuing education in the area of rehabilitation related to HIV and AIDS in the past 5 years beyond that received in their health degrees.

Rehabilitation Professionals’ Views on HIV Rehabilitation 

Despite the relatively low percentage (39%) of rehabilitation professionals who reported they worked with PHAs, 46% of respondents believed their profession is “very important” in the rehabilitation of PHAs. When asked how they perceived the role of other health providers in HIV rehabilitation, over 80% of respondents indicated that general practitioners, infectious disease specialists, nurses, pharmacists, social workers, dieticians, and AIDS service organizations (in areas of return to work, vocational rehabilitation, housing, and coping support) are “very important.”

Rehabilitation professionals were asked their views on the role of rehabilitation in the context of HIV and AIDS. They rated their level of agreement on a 4-point Likert scale (strongly agree to strongly disagree) for a variety of statements. Sixty-seven percent disagreed or strongly disagreed that rehabilitation professionals possess adequate knowledge and skills to assess and treat PHAs, and 91% strongly agreed or agreed that rehabilitation professionals who provide services for PHAs need specialized training. In contrast, 52% agreed or strongly agreed that working with PHAs is similar to working with people with other chronic illnesses, and 53% disagreed or strongly disagreed that serving PHAs is more demanding than serving patients with other chronic illnesses or conditions. Fifty percent agreed or strongly agreed that many rehabilitation professionals are uncomfortable with the idea of working with PHAs, and 46% agreed or strongly agreed that they personally believed that rehabilitation for PHAs should be a greater priority.

Rehabilitation Service Delivery Issues in the Context of HIV and AIDS 

Rehabilitation professionals were asked about barriers to rehabilitation and HIV service delivery. Seventy-four percent indicated that in the last year, waiting lists were a challenge to access and delivery of rehabilitation services, 72% indicated that funding issues (eg, underfunding) were a challenge, and 68% indicated availability of rehabilitation services. Forty-one percent of respondents believed that there were current barriers specific to HIV that might prevent PHAs from having their rehabilitation needs met, including stigma, fear, lack of available funding, lack of education of health care providers, and lack of available services in rural areas.

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Discussion 

This survey was the first in Canada to investigate the nature and extent of involvement of rehabilitation professionals in the provision of services to those living with HIV and their knowledge, attitudes, and practices in the context of HIV and AIDS. Despite the potential role for rehabilitation professionals in HIV care and treatment, results show that only a minority currently serves PHAs in Canada. Further, those who do serve PHAs serve very few, and PHAs who are served by rehabilitation professionals are largely seen for rehabilitation issues not related to HIV status. Thus, results of this survey show a potential gap between the documented rehabilitative needs of PHAs and the services currently provided by the rehabilitation professional community. Although reasons for this lack of congruence may reflect a complex set of personal and systemic features, findings from this survey enable us to describe the potential implications of personal factors—including views, knowledge, and training of rehabilitation professionals—on the provision of services for PHAs.

Views, HIV Knowledge, and Training 

The high proportion of rehabilitation professionals among those who had never knowingly served PHAs who were unwilling (27%) or uncertain (46%) whether they wanted to treat PHAs may be attributed in part to a combination of personal views and type of HIV knowledge and training received. Experienced clinicians in HIV rehabilitation suggest that the knowledge and skills required to work in HIV and AIDS is similar to those used with other populations and merely requires applying these skills in this unique context.12 Although just over half (52%) of survey respondents believed that working with PHAs is similar to working with people with other chronic illnesses, over 90% believed that rehabilitation professionals working in this field require specialized HIV training or knowledge. Thus, unwillingness or uncertainty to serve PHAs may be due to a sense of lack of qualifications or discomfort with working in a new field, particularly for those who have practiced longer. This was supported by our results that showed the number of years in professional practice was negatively associated with willingness to treat PHAs.

Personal attitudes and experiences also may influence willingness to treat PHAs. One of the strongest predictors of unwillingness or uncertainty about treating PHAs was the view that most rehabilitation professionals are uncomfortable with working with PHAs. In South Africa, even physical therapists who frequently work with PHAs reported minimal (30%) or moderate anxiety (15%) or fear (17%) when working with PHAs.18 Reduction in anxiety among rehabilitation professionals has been linked to younger age, amount of previous contact with PHAs, and contact with persons who were homosexual.19 Positive attitudes and reduced anxiety have also been linked to the amount of HIV information and knowledge possessed by social workers.20 Collectively this literature suggests that anxiety levels may be diminished with PHA interaction and HIV education to potentially increase rehabilitation professionals’ willingness to serve PHAs.

Few survey respondents had received HIV training as part of their rehabilitation degree program (27%) and even fewer (11%) had participated in specialty training or continuing education related to HIV and AIDS within the past 5 years. Our regression results indicate that among those survey respondents who had not served PHAs, receipt of specialty training was positively associated with willingness to treat PHAs. Studies of HIV education suggest that unless HIV education specifically addresses attitudes and feelings toward PHAs, willingness to provide services to this patient group may not change.21, 22, 23, 24 Thus, successful HIV and AIDS education for health professionals has included clinically based training opportunities25 and has integrated PHAs in interprofessional problem-based HIV education to challenge students’ assumptions of PHAs26, 27 and to increase factual knowledge about HIV and AIDS.

Current Rehabilitation Practices in the Context of HIV and AIDS 

Only 39% of survey respondents had knowingly served an HIV-positive patient in the last year, and the average number of patients served was low (4/y). This is less than in a U.K. study that found 62% of physical therapists had worked with PHAs.28 However, 2 of the U.K. institutions sampled were HIV specialist centers, and this likely resulted in an overestimation of physical therapists working in the HIV field.28 Because our survey included a random sample of all rehabilitation professionals (physical therapists, occupational therapists, speech-language pathologists, physiatrists) across Canada in all areas of practice, our findings may provide a better representation of the true proportion of rehabilitation professionals who have knowingly served PHAs.

The reasons rehabilitation professionals serve HIV patients are often unrelated to their HIV. Hence, a number of PHAs are likely living with HIV-related disablement not addressed by rehabilitation professionals. Disablement issues addressed by the rehabilitation professionals who served PHAs in our survey related primarily to problems with body structure or function (impairments) such as weakness or difficulties completing a task or action (activity limitations) such as decreased activity tolerance, more than problems of interacting within society (participation restrictions) such as vocational rehabilitation to return to work. Similar results have been reported in African countries.18, 29

Funding Structures and Geographic Variation 

Different rehabilitation funding structures and geographic variation appear to contribute to the low percentage of rehabilitation professionals who serve PHAs. Lack of funding and lack of available services, particularly in rural areas, were concerns noted by respondents that might keep PHAs from receiving rehabilitation services. Although barriers may exist in both public and private sectors, those faced in the private sector may be heightened if PHAs lack insurance or health benefits to cover associated costs. Our regression results suggest that working in British Columbia and some Atlantic Provinces (Nova Scotia, Prince Edward Island) were positively associated with serving PHAs compared with Ontario. Health care services are a provincial responsibility. Hence, practice differences may be attributed to differences in funding structure, the organization of the delivery of services, and a host of geographic and access factors. Further, the HIV epidemic varies depending on the province or community, which also may contribute to service patterns.30

Study Limitations 

This survey was conducted with a random sample of Canadian rehabilitation professionals. In these analyses, the focus was on the traditional rehabilitation professions; hence, we did not survey PHAs or other professionals (eg, chiropractors, massage therapists, housing support workers) who may have a role in HIV rehabilitation. Future research may address rehabilitation in the context of HIV from the perspective of these other stakeholders. In addition, although we established a comprehensive sampling pool from which to draw the sample, we were unable to access regulatory body lists from some provinces and territories; hence, the sample might not represent all practicing rehabilitation professionals across the country. Although the overall response rate was good (74%), the nonresponses (26%), ineligibles (10%), and refusals (12%) depleted the number of successfully completed questionnaires (53%). However, as a first survey about HIV rehabilitation among rehabilitation professionals, we believe this study adds significant information to the area.

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Conclusions 

Despite the role rehabilitation professionals have to play in HIV care and treatment, only a minority serves PHAs. The likely reasons for this gap are complex and multifactorial, spanning personal, geographic, funding, and systemic health delivery factors. This article focused on rehabilitation professionals’ views and HIV-specific knowledge and training. This study shows a need for effective education and service development in the field of rehabilitation in the context of HIV.

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Acknowledgments 

We thank the Canadian Working Group on HIV and Rehabilitation; the National Advisory Committee, including Elisse Zack, MEd, MMgt, Evan Collins, MD, Louis-Marie Gagnon, Barney Hickey, RN, Jim Marianchuk, RN, Arlis McQuarrie, BPT, and Christopher Sulway, MHSc, MCPA, CAFCI; professional organizations and regulatory bodies that provided mailing lists; and Kendra McLeish, MA, who assisted with regression modeling.

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 Supported by the Canadian Institutes of Health Research (grant no. HHP-64513); research fellowships provided by the Alberta Heritage Foundation for Medical Research and the Ontario HIV Treatment Network. The HIV Social, Behavioural and Epidemiological Studies Unit is funded by the AIDS Bureau, Ontario Ministry of Health, and the Faculty of Medicine, University of Toronto.

 No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the author(s) or upon any organization with which the author(s) is/are associated.

PII: S0003-9993(07)01661-9

doi:10.1016/j.apmr.2007.10.009

Archives of Physical Medicine and Rehabilitation
Volume 89, Issue 1 , Pages 105-113, January 2008

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