008 Layout SA JOURNAL OF PHYSIOTHERAPY 2009 VOL 65 NO 2 13 INTRODUCTION The Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS) have continued to spread in Southern Africa despite public awareness campaigns related to pre- vention. By the end of 2005, Botswana had a national HIV prevalence of 24% among adults in a population of only 1,640,115 (UNAIDS, 2006). Although there are reduced global infection rates, Botswana remains one of the hardest stricken countries in the world (UNAIDS, 2007). While many people living with HIV/AIDS (PLWHA) on anti-retroviral drugs (ARVs) are experiencing an improved life span (Palella et al, 1998), they are also experiencing more chronic health problems (Wood et al, 2000) and impairment and disability is increasing (Rusch et al, 2003). As a consequence physiotherapists are working with increasing numbers of people with HIV related conditions (Gale, 2003). Studies have reported on the beneficial role of physiotherapy in the management of neurological, musculoskeletal, respira- tory, and painful syndromes among HIV infected people (Gale, 2003; Jose and Balan, 2002; Ondoga, 2002; Sacky, 1998). However, there are limited studies on attitudes of physiotherapists towards treating PLWHA (Voors, 2000), despite research done on the attitudes of other healthcare professionals (Worthington et al, 2005). The aim of this study was to determine the attitudes of physio - therapists in Gaborone and Ramotswa, Botswana, towards treating people living with HIV/AIDS. METHOD This descriptive study was carried out using qualitative methodology. The research sample and process are described in detail to facilitate transfer- ability, a component of trustworthiness (Denzin and Lincoln, 1998; Guba and Lincoln, 1998). A purposive sample consisting of 10 registered physiothera- pists working in government hospitals, private hospitals and clinics who had work-related experience with PLWHA was included in the study. In an attempt to ensure rich data, participants with very different demographic characteris- tics were selected. Four of the physio- therapists were male and six female. Their ages ranged from 22 years to over 40 years. The participants’ nationalities included four Botswana physiotherapists, two Zimbabwean physiotherapists, two Indian physiotherapists, one Kenyan physiotherapist and one Zambian physio - therapist (Botswana does not have a Physiotherapy training facility so many physiotherapists working there are foreigners). The majority of the physio- therapists were working in state hospi- tals with a minority in the private sector. Half of the physiotherapists had work experience of between one and five years, with others having at least six years work experience. Individual in-depth interviews were conducted in English using a semi-struc- tured interview guide with open ended questions that was based on previous research on attitudes of health care workers to PLWHA. The interviews, lasting on average of 40 minutes, took place at physiotherapy departments. With the agreement of the participants, a tape recorder was used to record the interview and field notes were taken. The recorded interviews were transcribed Attitudes of physiotherapists in Botswana to treating people living with HIV/AIDS R e s e a r c h A r t i c l e A BST R A CT: Physiotherapists are increasingly treating people living with HIV /A IDS. However, there is little information reported on either their attitudes when providing treatment to people with HIV /A IDS, or what facilitates positive attitudes. This study aimed to determine the attitudes of physiotherapists in Botswana towards treating people living with HIV /A IDS. A qualitative approach was used with a purposive sample of 10 physiotherapists working in hospitals and private clinics in Gaborone and Ramotswa. In-depth interviews were conducted with individual physiotherapists, utilising an interview guide in. The results indicated that most physiotherapists had a positive attitude towards treating people living with HIV /A IDS. The positive attitude was associated with interrelated factors including their experience with people living with HIV /A IDS (PLW HA ); knowledge of HIV /A IDS; job satisfaction; and a belief in a duty to treat all. A few physiotherapists had a negative attitude which was related to being judgmental and to a fear of acquiring HIV through occupational infection. KEY W ORDS: HIV /A IDS, ATTITUDE, PHY SIOTHERA PISTS, TREATMENT, PEOPLE LIV ING W ITH HIV /A IDS. Kambole M, MSc Physiotherapy1; Struthers P, PhD1 1 University of the Western Cape. Correspondence to: Prof Patricia Struthers Physiotherapy Department, University of the Western Cape Private Bag X17 Bellville 7535 South Africa Email: pstruthers@uwc.ac.za Fax: (021) 959-1217 memulenga@yahoo.com 14 SA JOURNAL OF PHYSIOTHERAPY 2009 VOL 65 NO 2 and then analysed manually using content analysis. Codes were identified; differences and similarities were identi- fied and the codes were sorted into categories. Subsequently themes were identified. To ensure dependability the researcher’s supervisor reviewed the transcripts, the coding and identification of categories and themes. Throughout the process a reflexive journal was kept to assist the researcher in distinguishing her personal experiences and attitudes from those of the participants thus ensuring credibility and confirmability (Krefting, 1991). Ethical considerations included ethi- cal approval by the University of the Western Cape, South Africa, where the researcher was a student. Permission was also obtained from Research Unity, Botswana Ministry of Health and the management of each hospital. Each par- ticipant was given detailed information about the study and requested to sign a consent form, confirming voluntary participation and their right to withdraw from the study. The findings are reported using pseudonyms to maintain confiden- tiality. The words of the participants are used to facilitate confirmability. RESULTS The themes that were identified include the experiences and feelings about PLWHA; judgmental and non-judg mental attitudes; willingness to treat PLWHA; challenges experienced; and coping strategies. Experiences and feelings about PLWHA All the physiotherapists indicated they had extensive experience of working with PLWHA. All the African physio- therapists said they had relatives or close friends living with the HIV infec- tion or who had died from AIDS related illnesses. They described feelings of sadness, pain and compassion towards PLWHA. One physiotherapist expressed deep emotion: It is painful and sad ... these are young people very close to you. (Mpho*1) There was, however, one physiothera- pist who said she felt neutral feelings towards treating PLWHA. She said they did not affect her emotionally: My feeling about them is the same as I feel for other patients with communica- tive diseases. (Linda) Judgmental and non-judgmental attitudes Some physiotherapists expressed judg- mental attitudes towards PLWHA. This was based on whether or not they felt PLWHA should be blamed for their status. Certain people such as men who had sex with multiple partners and sex workers were blamed for being care- less and lacking commitment to HIV prevention. Some people especially men get it out of negligence ... (Arishina) However, some physiotherapists were less judgmental and indicated that no one deserved HIV irrespective of how they got it. ... what is important is to make a person live positively. (Linda) Willingness to treat PLWHA All the physiotherapists indicated that they were willing to treat PLWHA. They indicated that PLWHA needed as much, if not more, caring from the physio therapist as other patients. They are also human beings ... they need us to be more caring towards them. (Vimkita) A positive attitude was influenced by several factors. The first factor was the physiotherapist’s experience with PLWHA. Physiotherapists with relatives and friends infected with HIV talked of how their experiences enabled them to have compassion and confidence to treat PLWHA. My experience with infected friends and relatives makes me to understand what they are going through and confidently treat them like any one else. (Edwin) The second factor contributing to a positive attitude to treating PLWHA was the physiotherapist’s knowledge of HIV/AIDS. These physiotherapists spoke about how their improved knowledge about HIV/AIDS had given them con - fidence to treat patients. It was scary many years ago... but now with a lot of information everywhere, you know that you cannot get it that easily. (Vimkita) HIV/AIDS knowledge has helped us improve to handle these patients in better way. (Linda) The third factor contributing to a posi- tive attitude to treating PLWHA was self-fulfillment. Despite challenges faced in treating patients with HIV related conditions, some participants found it fulfilling when patients improved as a result of their treatment. Knowing that I had made some positive change in one’s life sometimes gives me a job satisfaction. (John) The final factor identified as leading to a positive attitude to treating PLWHA was the sense that the physiotherapist has a duty to treat all patients. All the parti - cipants believed they had no option to refuse to treat any patient. A patient is a patient, whether HIV positive or not, you do not need to dis- criminate. (Kenn) If you as a health worker cannot treat an HIV/AIDS patient, then you are in a wrong field. (Edwin) Challenges to treating PLWHA One of the challenges the physiothera- pists indicated that they faced was the risk of contracting HIV infection at work. But this concern was only mentioned by a small number of the participants. The second challenge the physio - therapists mentioned was that they found working with PLWHA emotionally draining particularly when treating PLWHA in their final stage of illness * All names have been changed SA JOURNAL OF PHYSIOTHERAPY 2009 VOL 65 NO 2 15 where they might need to come to terms with the death of the patient. Physiotherapy treatment often continues over a long period of time resulting in therapists forming close bonds with their patients making it particularly difficult for the physiotherapist when the patient dies. ...for anyone it could be emotionally draining to treat patients struggling and fighting for survival. (Taji) ...that is draining... sometimes I feel helpless. (John) The third challenge the physiotherapists mentioned was that they found it diffi- cult to support patients with emotional problems related to their illness. Though they have gone through coun- selling and you have tried your best but they can’t just come to terms. (Linda) The fourth challenge that some physio- therapists spoke of was how it was dif - ficult to work with patients with differ- ent cultural beliefs, who were seeking physiotherapy services at the same time traditional medical treatment. Even if someone has been told you are HIV positive, they still feel they have been bewitched. (Edwin) The fifth challenge that physiotherapists spoke of was that they were expe - riencing an increasingly heavy workload due to the growing number of PLWHA while the small number of physiothera- pists in state hospitals was not increasing. Even though we want patients to be referred, sometimes the load is just too much to us. (Linda) The sixth challenge was the disappoint- ment experiences by some physio - therapists at the delayed referral of patients with HIV related conditions for physiotherapy from medical doctors. This delay in referral might be due to doctors’ uncertainty about the benefits of physiotherapy for these patients or because of poor communication within the health system. Doctors delay referring patients for physiotherapy. (Kenn) If we were involved earlier on, things like muscle wasting and other complica- tions can be avoided or delayed. (Mpho) Coping strategies Physiotherapists spoke of how they coped with these challenges by sharing their difficulties with their colleagues. They were trying to learn more about the nature of HIV/AIDS and its develop- ment into a chronic disease. However, these strategies appeared inadequate especially for young physiotherapists with few years of experience. Discussion The findings in this study indicate that there is largely a positive attitude among physiotherapists’ in Botswana to treat- ing PLWHA. This is consistent with Salati (2004) who did a study among physiotherapists in Zambia, and Smit (2005) who did a study among nurses in South Africa. Most participants indicated strong empathetic feelings and non- judgmental attitudes. Positive attitude to treating PLWHA appears to be influ- enced by a combination of factors, not one single factor. The key factors in the development of a positive attitude appear to be a relationship between the personal and work-related experience that the physiotherapists had with PLWHAs; improved knowledge about HIV and AIDS; and the balance between gaining a sense of self-fulfillment from treating a patient and a sense of a duty to treat all patients. These factors seemed to outweigh a number of challenges encountered such as fear of the risk of infection; finding the interaction with PLWHA emotional draining; experienc- ing difficulty with supporting patients with emotional problems; understanding patients’ cultural beliefs; an increasing workload; and receiving delayed referrals from medical practitioners. However, if these challenges are not addressed it is possible for a shift in balance to take place with negative factors increasingly playing a role. Although all the physiotherapists said they were willing to treat all patients, this does not correspond with every- one’s attitude. The indication of willing- ness could have been due to the physio- therapists’ ethical commitment of a “duty to treat all patients”. The negative attitude that was present among a few physiotherapists was largely the result of their concern about occupation infec- tion. However, in practice, the risk of physiotherapists acquiring HIV at work is very low because they do not carry out invasive procedures (Voors, 2000). They are unlikely to be exposed to infection if they comply with universal precautions as specified by WHO (2003). Other studies also report on this excessive fear among physiotherapists of being at risk (Puckree et al, 2002; Useh et al, 2003). Judgmental views also influenced negative attitude with some PLWHA being spoken about as if they deserved to be ill. This may be because HIV is largely transmitted through sex. As in many other parts of Africa, in Botswana there is a strong opposition to homo - sexuality, sex work, and drug use. This includes legislation prohibiting these activities. To a lesser extent, there is opposition to people having multiple concurrent heterosexual partners both in and outside of marriage, the most common cause of the spread of HIV in sub Saharan Africa. As a consequence positive HIV status is considered a con- sequence of engaging in what society considers “immoral behavior” and is frequently associated with sexually “marginal” groups of people. Similar judgmental views have been reported by Lau and Tsui (2005) in China and and Valdiserri (2002) in the USA. CONCLUSION Most physiotherapists in this study in Botswana had a positive attitude to treating PLWHA. Positive attitude to treat was facilitated by a combination of factors. These include increased expe - riences of working with PLWHA; improved knowledge of HIV/AIDS; a sense of self-fulfillment; and a duty to treat all patients. RECOMMENDATIONS There is need for continuous education for physiotherapists, firstly to update their knowledge of HIV and AIDS, and, secondly, to develop their counselling 16 SA JOURNAL OF PHYSIOTHERAPY 2009 VOL 65 NO 2 skills. There is a need for a formal emotional support system for the physio - therapists and PLWHA. 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