24 SA JOURNAL OF PHYSIOTHERAPY 2003 VOL 59 NO 1 mation of hepatitis B seems to be theo- retical and not practical (Clayton et al, 1993). An increase in knowledge of HIV/AIDS in physiotherapy and occu- pational therapy students led to a positive influence on their regard towards patients, but did not improve their willingness to work with these patients (Balogun et al, 1997). A previous study determined that the attitude of physiotherapists in Bloemfontein is positive towards treating HIV/AIDS patients although some moral questions were posed. More than half (58%) of these physiotherapists did not have an adequate working knowledge of the preventative measures for HIV trans- mission (Barr et al, 1994). The aim of the study was therefore to determine whether physiotherapists practising in the Free State have adequate knowledge of the transmission and prevention of tuberculosis, hepatitis A, B and C and HIV/AIDS. METHODS A descriptive study was conducted. All practising physiotherapists in the Free ABSTRACT: With the world-wide increase of communicable diseases, adequate knowledge by health professionals of the transmission and prevention of these diseases is essential to ensure effective protection. The aim of this study was to determine whether practising physiotherapists’ knowledge of the transmission and prevention of tuberculosis, hepatitis A, hepatitis B, hepatitis C and HIV/AIDS was adequate to ensure effective protection. A descriptive study was conducted. One hundred and forty six practising physiotherapists in the Free State received questionnaires on which they had to indicate the relevant transmission and preventative measures for each disease. One hundred and three (70.5%) questionnaires were returned. Points were allocated for the knowledge of transmission and preventative measures. The medians with respect to transmission were: tuberculosis 83%, hepatitis A 58%, hepatitis B 67%, hepatitis C 75% and HIV/AIDS 92%. The medians with respect to preventative measures were: tuberculosis 57%, hepatitis A 58%, hepatitis B 77%, hepatitis C 67% and HIV/AIDS 71%. The knowledge of trans- mission was better than the knowledge of preventative measures. An increase in the knowledge of practising physio- therapists in the Free State is needed to ensure their maximal protection against communicable diseases. KEY WORDS: TUBERCULOSIS, HEPATITIS, HIV/AIDS, KNOWLEDGE, TRANSMISSION, PREVENTION PHYSIOTHERAPISTS’ KNOWLEDGE OF THE TRANSMISSION AND PREVENTION OF COMMUNICABLE DISEASES CORRESPONDENCE TO: L Grobler Department of Physiotherapy, University of the Free State, PO Box 339, Bloemfontein 9300 R E S E A R C H A R T I C L E INTRODUCTION Physiotherapists are constantly in contact with a variety of patients and diseases, and thus run an increased risk of infection. In South Africa, 1000 people die of tuberculosis every month (Collins, 2000), 1700 are infected with HIV daily (Orlovic, 2000) and roughly 60% of adults have been infected with hepatitis B (Yach & Buthelezi, 1995). A study by Buso et al (2000) reported that few South African doctors knew the correct diagnostic protocol for pulmonary tuberculosis. Doctors in a middle income county in China appeared to understand the transmission of hepatitis B, but confused it with hepatitis A. Doctors who had not gained the village doctor certificate appeared to have the greatest need for further education and infor- State were included. Addresses were obtained from the SA Physiotherapy Association (Free State), Private Practice Association, Provincial Head of Clinical Physiotherapists, telephone directories and personal enquiry. Participation was voluntary and confidentiality was ensured. The Ethics Committee of the Faculty of Health Sciences, University of the Free State (UFS) approved the study. A questionnaire was compiled and consisted of the following segments: demographic information, general knowledge and knowledge regarding transmission and preventative measures of tuberculosis (TB), Hepatitis A-virus (HAV), hepatitis B-virus (HBV), hepa- titis C-virus (HCV) and HIV/AIDS. Participants had to indicate whether a certain preventative measure was always essential, desirable, or never essential. In Bloemfontein, questionnaires were delivered by hand and questionnaires were mailed to physiotherapists in the rest of the Free State. Stamped envelopes were included. GROBLER L1, KLEYNHANS N1, LUBBE A1, SMIT T1, RETIEF C1, VICTOR D1, BESTER CJ2 1 Department of Physiotherapy and 2 Department of Biostatistics, University of the Free State, Bloemfontein. To keep bias and variation to a mini- mum the following was done: • Questionnaires were compiled under supervision of the Department of Biostatistics after a literature review and consulting with experts on com- municable diseases and on compiling questionnaires. A pilot study was also conducted in which eight non-practising lecturers (Department Physiotherapy, UFS) completed the questionnaire. • A covering letter attached to each questionnaire, explained that dis- cussing or retrieving additional infor- mation to answer the questionnaire would influence the results. The correct answers for the questions were obtained from various relevant sources (Collins, 1989; Benenson, 1990; Mandell et al, 1990; WHO Fact Sheets WHO/204 and WHO/164, 2000; and WHO vaccines, 2002). Descriptive statistics, namely fre- quencies and percentages for categorical data, and means and standard deviations or medians and percentiles for conti- nuous data were determined by the Department of Biostatistics, UFS. An information leaflet with the rele- vant information as well as the results of the study was sent to all participants. RESULTS One hundred and three (70.5%) of the 146 questionnaires were returned. The demographic information is summarised in Table 1. The respondents were pre- dominantly female (92%) and practising in Bloemfontein (69%), with a median of 7 years practical experience. Transmission Table 2 summarises the method of trans- mission of the relevant diseases. Tuberculosis: All participants (103) answered the TB section, but one person marked all the options and was excluded. Six participants scored the maximum of 100% and 2 participants scored the minimum of 42%. The participants who marked the option “other” did not spe- cify anything except one who specified “contact with air”. A large percentage of participants correctly knew that TB was transmitted via sputum (84%) and nasopharyngeal secretions (78%). A smaller percentage (65%), however, marked that TB was transmitted via aerosols. Hepatitis A: Twelve participants did not complete the HAV section and one participant marked all the options and was excluded. Two participants scored the maximum of 83% and one partici- pant scored the minimum of 25%. Three participants marked the option “other”, but did not specify anything. The main route for HAV transmission is the faecal-oral route, but HAV is also transmitted via nasopharyngeal secretion, sputum and aerosols. Few participants, however, marked these routes (Table 2). Table 1: Demographic information of participants (n=103) Male 8 (8%) Female 95 (92%) Mean age 30 years (range 21 - 60) Location of practice: Bloemfontein 69% Rest of Free State 31% Type of practice: Full-time private 51% Part-time private 15% Full-time hospital 40% Part-time hospital 16% Academic 6% Other (eg. School, 8% home consultations, community) Table 2: Method of transmission of the relevant diseases Method of transmission Chosen option (% participants) TB HAV HBV HCV HIV/AIDS (n = 102) (n = 90) (n = 95) (n = 85) (n = 101) Faecal - oral 26 69 55 39 45 Nasopharyngeal secretions (without blood) 78 32 31 18 20 Aerosols 65 22 17 8 6 Saliva (without blood) 65 31 37 16 16 Urine (without blood) 14 25 40 23 24 Blood 27 53 79 67 99 Needle pricks 13 45 69 46 94 Sputum (without blood) 84 38 39 21 22 Sweat 4 15 11 5 6 Tears 4 7 7 3 8 Faeces (without blood) 17 42 37 28 31 Sexual secretions 14 23 40 23 78 Other (specify) 6 3 10 5 14 Shaded area = Correct option SA JOURNAL OF PHYSIOTHERAPY 2003 VOL 59 NO 1 25 26 SA JOURNAL OF PHYSIOTHERAPY 2003 VOL 59 NO 1 Hepatitis B: Seven participants did not complete the HBV section and one participant marked all the options and was excluded. Nine participants scored the maximum of 92% and one partici- pant scored the minimum of 25%. Only 37% of the participants marked the cor- rect options “sputum (without blood)” and 40% marked “sexual secretions”. Participants were more knowledgeable about the transmission routes “blood” (79%) and “needle pricks” (69%) [only 0.0004ml blood is needed for the trans- mission of HBV and physiotherapists have to be aware of the high risk involved]. Hepatitis C: Sixteen participants did not complete the HCV section and 2 participants marked all the options and were excluded. Ten participants scored the maximum of 100% and 4 participants the minimum of 42%. The participants who marked “other” did not specify anything. Participants marked the cor- rect transmission routes “blood” (67%) and “needle pricks” (46%), and many marked the incorrect options “faecal- oral” (39%) and “faeces (without blood)” (28%). A lack of HCV knowledge could account for the many transmission options marked. HIV/AIDS: All participants answered the HIV/AIDS section. Two participants marked all the options and were excluded. Twenty-three participants scored 100%, one participant scored the minimum of 33%. Those who marked the option ‘other’ did not specify anything. Preventative measures The preventative measures for hepatitis (HAV, HBV and HCV) transmission are summarised in Table 3 and for TB and HIV/AIDS in Table 4. The correct options are highlighted. Hepatitis A: For HAV (Table 3), 8 of the 11 preventative measures are always necessary. The percentage participants that chose the correct “Always” option ranged from 64% to 92%. Although “Desirable” was the correct option for the 3 remaining questions, most parti- cipants chose the “always” option (48% Table 3: Preventative measures for hepatitis transmission Preventative measure HAV HBV HCV Always Desirable Never n Always Desirable Never n Always Desirable Never n (%) (%) (%) (%) (%) (%) (%) (%) (%) Washing hands 92 8 0 96 4 0 100 93 7 0 95 Disinfecting hands 67 32 1 100 78 22 0 100 68 32 0 95 Wearing gloves 58 38 4 99 81 18 1 101 61 36 3 94 Wearing gloves if excretions (urine and faeces) are present 80 20 0 100 81 18 1 101 65 34 1 95 Wearing gloves if visible blood is present 80 19 1 100 93 6 1 100 88 11 1 94 Wearing gloves if saliva, sputum and nasopharyngeal secretions are present 62 36 2 98 76 22 2 100 66 31 3 94 Wearing a mask 48 36 16 100 60 32 8 100 55 39 6 95 Wearing a mask if infective material can splash 81 17 2 99 87 12 1 101 Wearing a plastic apron 44 51 5 94 Wearing a plastic apron if excretions (urine and faeces) are present 65 32 3 99 66 31 3 101 60 37 3 94 Wearing a plastic apron if saliva, sputum and nasopharyngeal secretions are present 61 37 2 100 52 46 2 93 Wearing a plastic apron if infective material can splash 73 25 2 100 81 18 1 101 71 28 1 94 Wearing eye protection if infective material can splash 85 13 2 100 Sterilise vectors (e.g. stethoscope) after contact with patient 64 31 5 99 70 30 0 100 Putting terminal phase patient in a single room 45 47 9 92 Shaded area = Correct option SA JOURNAL OF PHYSIOTHERAPY 2003 VOL 59 NO 1 27 to 62%). Three participants marked the “other” option, but did not specify anything. Hepatitis B: For HBV (Table 3) 11 of the 13 preventative measures is always necessary. The percentage participants that chose the correct “Always” option ranged from 61% to 96%. Although “Desirable” was the correct option for the remaining 2 questions, most partici- pants chose the “always” option (60% and 81%). Only 17.8% and 32%, respec- tively, chose the correct “desirable” option with “wearing gloves” and “wearing a mask”. This indicates either a more practical approach of the participants, over caution, or a constant choice of the same option. Two participants marked the “other” option, but did not specify anything. Hepatitis C: Eight participants did not complete the section for HCV (Table 3). Seven participants gave no reason, and one participant stated that he/she had no knowledge of the disease. Five partici- pants marked the “other” option, but did not specify anything. Tuberculosis: For TB (Table 4), only 2% of the participants marked the cor- rect option of “never” for the question “wearing gloves when excretions (urine and faeces) are present”. No participant marked the correct option “never” for the question “wearing gloves when visible blood is present”. Five participants marked the “other” option, but only 2 specified the following: “wearing a mask and glasses”, and “wearing glasses is desirable”. Table 4: Preventative measures for TB and HIV/AIDS transmission Preventative measure TB HIV/AIDS Always Desirable Never n Always Desirable Never n (%) (%) (%) (%) (%) (%) Washing hands 97 3 0 100 91 9 0 101 Disinfecting hands 65 34 1 102 72 25 3 101 Wearing gloves 58 40 2 100 73 26 1 99 Wearing gloves if excretions (urine and faeces) are present 76 22 2 102 75 23 2 100 Wearing gloves if visible blood is present 75 25 0 101 94 5 1 101 Wearing gloves if saliva, sputum and nasopharyngeal secretions are present 85 15 0 102 77 22 1 100 Wearing a mask 84 16 0 101 Wearing a mask if infective material can splash 93 7 0 100 Wearing a cap with endo-tracheal suction 52 39 9 100 Wearing a cap if infective material can splash 61 29 10 98 Wearing a plastic apron 40 54 6 101 Wearing a plastic apron if excretions (urine and faeces) are present 49 47 4 101 67 29 4 100 Wearing a plastic apron if saliva, sputum and nasopharyngeal secretions are present 64 34 2 101 61 37 2 101 Wearing a plastic apron if infective material can splash 82 17 1 101 83 15 2 102 Wearing eye protection if infective material can splash 89 9 2 102 Sterilise vectors (e.g. stethoscope) after contact with patient 70 27 3 99 67 31 2 100 Putting terminal phase patient in a single room 57 40 3 100 42 40 18 102 Shaded area = Correct option 28 SA JOURNAL OF PHYSIOTHERAPY 2003 VOL 59 NO 1 HIV/AIDS: For HIV/AIDS (Table 4), 12 of the 14 preventative measures always need to be taken. The percentage of participants who chose the correct “Always” option varied from 42% to 94%. Although the correct option was “desirable” for the remaining 2 preven- tative measures most participants chose the “Always” option. Only 26% and 31%, respectively chose the correct option of “wearing gloves” and “sterili- sation of vectors (e.g. Stethoscope) after contact with patient”. Two participants marked the option “other”, but did not specify anything. The minimum, median and maximum percentage of correct answers given for TB, HAV, HBV, HCV and HIV/AIDS are summarised in Table 5. For TB, HCV and HIV/AIDS the median percentage of correct answers for transmission was higher than that for prevention. DISCUSSION Knowledge of the method of trans- mission is in general better than that of preventative measures for the diseases studied (Table 5). The median percentage for the knowledge of method of transmission for HIV/AIDS is 91.7%. The high percentage of participants that marked blood (99%) and needle pricks (94%) could be ascribed to the large amount of publicity that HIV/AIDS receives. It is, however, strange that 45% of the parti- cipants marked faecal-oral as a method of HIV/AIDS transmission. Responses with regard to preven- tative measures indicate a more practical approach of the participants, over caution, or a constant choice of the same option. Many participants in private practice may feel that they do not often come into contact with the diseases and there- fore that the diseases do not pose any real threat to them. This may be a pos- sible explanation why their knowledge of method of transmission and preven- tative measures is not comprehensive. It is, however, imperative that physio- therapists protect themselves as these diseases have asymptomatic periods vary- ing from two weeks to years. The knowledge of communicable dis- eases could be reinforced by publishing the results and inclusion into the physio- therapy pre-graduate curriculum. CONCLUSION Tuberculosis, hepatitis A, B and C and HIV/AIDS are growing problems in South Africa. Knowledge of these diseases is needed to ensure optimal protection for the physiotherapist. The study shows that the physiothe- rapist’s knowledge of transmission and preventative measures of these diseases is relatively good, but not adequate to ensure their optimal protection. REFERENCES Balogun JA, Kaplan MT, Miller TM 1998 The effect of professional education on the knowledge and attitudes of Physical therapist and occupational therapist students about Acquired Immunodeficiency Syndrome. Physical Therapy 78(10): 1073-1082 Barr C, de Wet T, van Wijck V, Walters L 1994 ’n Ondersoek na die houding en kennis van fisioterapeute met betrekking tot die behan- deling van VIGS pasiente. Bloemfontein: Final year physiotherapy student script, University of the Free State Benenson AS 1990 Control of communicable disease in man. Washington DC: American Public Health Association Table 5: Participants’ knowledge of transmission and prevention of communicable diseases Disease Transmission Prevention (% correct answers) (% correct answers) Minimum Median Maximum Minimum Median Maximum TB 42 83 100 21 57 71 HAV 25 58 83 8 58 92 HBV 25 67 92 15 77 100 HCV 42 75 100 0 67 92 HIV/AIDS 33 92 100 7 71 93 Buso DL, Jinabhai CC, Hausler HP 2000 Knowledge, attitudes and practices of private doctors with respect to national TB control programme - a national survey. The Southern African Journal of Epidemiology and Infection 15:68-73 Clayton S, Yang H, Guan J, Lin Z, Wang R 1993 Hepatitis B control in China: Know- ledge and practices among village doctors. American Journal of Public Health 83:1685- 1688 Collins TFB 1989 Tuberculosis: Understanding and managing the disease: a handbook for medical students and general practitioners and senior nurses. Johannesburg: South African National Tuberculosis Association Collins T 2000 TB - Are we losing the battle? South African Medical Journal 90(3): 237-238 Kirsch RE, Abdool Karim SS, Prozesky OW 1994 Why viral hepatitis? South African Medical Journal 84(8): 523 Mandell GL, Douglas R, Bennett JE 1990 Principles and practice of infectious diseases. New York: Churchill Livingstone Orlovic D 2000 Tuberculosis in HIV - infected patients. Continual Medical Education 18(4): 330-335 WHO Information Fact Sheets 2000. Hepatitis B Fact Sheet WHO/204. Available at: http://www.who.int/inf-fs/en/fact204.html WHO Information Fact Sheets 2000. Hepatitis C Fact Sheet WHO/164. Available at: http://www.who.int/inf-fs/en/fact164.html WHO Vaccines, Immunization and Biologicals 2002. Hepatitis A vaccine. Available at: http://www.who.int/vaccines/ en/hepatisisa.shtml Yach D, Buthelezi G 1995. Chapter 3. Health Status. In: South African Health Review, Part I. Imperatives for health systems reform. Available at: http://www.hst.org.za/sahr/ chap3.htm