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RESEARCH REPORT

Physiotherapists’ Perceptions of Risk of HIV Transmission in Clinical Practice Lesleu Dike

Key Words Physiotherapist, human immunodeficiency virus (HIV), risk perception. Summary The perceived risk of HIV transmission in clinical practice among physiotherapists was investigated in one large hospital in an area of low HIV prevalance. A convenience sample of 30 staff of all grades was anonymously surveyed using a questionnnaire. The response rate was high (90%). Physiotherapy was viewed as a comparatively low-risk medical profession, with respiratory care presenting most perceived risk. Staff differed in their knowledge about body fluids and expressed different levels of confidence in treating HIV positive patients. Some staff felt they had a right to know patients’ HIV status. The level of discrepancy in knowledge and perception showed there was a need for guide lines on this subject for physiotherapists.

Introduction Despite the high public profile given to HIV and AIDS in recent years, very little mention has been made of them in relation to physiotherapy. Very few physiotherapy articles or papers make specific reference to the virus and its management. Notable exceptions are Coates (1990), Sim and Purtilo (19911, Sim (1991) and Galantino and Dellagatta (1990). The Chartered Society of Physiotherapy (CSP) has not issued its own practice guide lines on the subject but, on request, distributes general infection control details, plus guide lines produced by individual health authorities (Collier, 1987; Richmond, Twickenham and Roehampton HA, 1987). Looking to other therapies, specific information is available from, for example, the British Association of Occupational Therapists (19871, and the College of Speech Therapists (1990). All health workers are deemed to face occupational risk of HIV at work (US Department of Health and Human Services, 1987). All occupational transmissions are closely monitored and categorised according to profession. However, to date, no documented case of seroconversion to or from a physiotherapist has been reported.

The risk for certain medical professions has been quantified on the basis of current exposures and much more has been done to survey both knowledge and attitudes among many health workers, which has included some data on risk perception (eg Klimes et al, 1989). However, similar information relating to risk factors for physiotherapists has not been produced. Similarly, physiotherapists have not been surveyed about HIV in relation to their profession. Thus a gap in research was identified.

Surveying attitudes and knowledge about a controversial social issue, such as HIV, is difficult to do objectively,

particularly as respondents may censure their own socially unacceptable answers. Risk perception therefore was chosen as the research topic, to reflect an aspect of physiotherapists’ working life. It was anticipated that risk perception would also indirectly show a relationship to attitudes and knowledge.

The primary aims of the study were to make an initial exploration into physiotherapists’ perceptions of the potential risk of HIV transmission in clinical practice; to investigate the nature of any risks perceived, to assea the accuracy of the perceived risk; to evaluate the need for specific HIV guide lines for physiotherapists.

A secondary aim was to generate ideas for further action and research. As Stone (1991) says of qualitative research: ‘The major goal is often one of gaining as much insight as possible into the situation under consideration.’

Given that no documented case of transmission within the profession has been reported, and given the low profile of HIV within physiotherapy, the hypothesis was formed that physiotherapy would be seen as presenting potentially low-risk transmission in comparison to other medical professions. It was hypothesised that knowledge levels would vary and that different levels of clinical confidence would be expressed. The lack of information currently available provided the projection that guide lines specific to physiotherapy would be needed.

Method A convenience sample (30) was selected from the physiotherapy department of a large teaching hospital. It was considered appropriate that an exploratory survey of this kind should target a maximum number of respondents within a given population. This would then provide a viable representation of the whole population. Thus, the maximum number of staff was targeted, allowing for leave, sickness and so on.

A strong emphasis therefore was placed on achieving maximum possible response, to increase study viability. In recognition of the sensitive subject matter, and the possible detrimental effect this sensitivity could have on response levels, anonymity was given a high priority. This was ensured in the following ways:

1. The superintendent distributed questionnaires to 30 staff (85% of total). 2. Each questionnaire was in a self-completion format, anonymous and uncoded, and each was returned in an unmarked sealable envelope to a department pigeon-hole. These responses were collected two weeks later. One questionnaire was collected a t a later date. 3. Staff grade was the only personal detail required. It was felt that work specialty details would reduce confidence in anonymity.

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4. The author declined an invitation to introduce the questionnaire to participating staff to avoid any undue experimenter bias.

The only specification made was that all grades of staff should be involved, from as wide a variety of specialties as possible (this was also ensured by targeting 86% of the workforce). Variables such as age, level of training in HIV/AIDS, previous clinical experience of HIV/AIDS and work specialty were not controlled for. All staff members were female. The location was an area of low HIV prevalence.

Seven questions were asked of each respondent, using open and closed queries, providing both nominal and ordinal data. Respondents were asked to qualify certain answers and were invited to give comments. It was anticipated that this approach would give more flexibility to the method, provide more insight, and possibly raise issues of concern that had not been predicted. This approach was also thought to be more ethical, given that the study aimed to engender ideas for other research.

It was explained to each respondent that the research was a course requirement for the author, whose name was given. The purpose of the study was briefly mentioned.

Results Nine participants (33%) were junior grade, 9 (33%) senior II ,8 (30%) senior I, and one (4%) a superintendent. A range of grades was thus achieved. The response rate was extremely high - 27 respondents (90%).

Question 1. in comparison to other medical professions, what potential risk of HIV transmlsslon does physiotherapy carry? Please rate on a scale 0-4, putting highest risk at 4.

The professions that were perceived as low-risk were physiotherapy and general practice, while other medical professions were rated more highly (fig 1). Fourteen (52%) rated physiotherapy as risk 1; 7 (26%) rated it risk 2. The remaining 6 (22%) rated the profession as either

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Fig 2: Respondents' perceptlon of rlsk 4 HIV transmission for varlous health-care professlono

risk 0 (3%) or risk 3 (3%). None rated it on the highest scale. General practice received very similar ratings: risk 0-4 (16%), risk 1-12 (48%), risk 2-6 (24%), risk 3-2 @%I, risk 4-1 (4%). Professions perceived as carrying a high risk are shown in figure 2. Surgery and casualty were both rated risk 4 by 17 (63%). Dentistry was rated risk 4 by 11 (41%) and risk 3 by a further 8 (30%). The highest rating for nursing was risk 3 by 11 (44%) and general practice was rated at risk 1 by 12 (48%).

The only profession not rated risk 4 by any respondents was physiotherapy. Each of the six professions was given risk 0 status by a nominal percentage; 2 (7%) rated all professions the same, either as risk 0 or 1. Twenty-five (93%) perceived a hierarchy of risk among different professions.

Risk 2 Risk 3

Fig 1: Respondents' perception of potential rlsk of HIV transmission withln physiotherapy, dentistry, surgery, nursing, casualty and general practlce

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Fig 3: Respondents’ perception of risk of HIV transmission within respiratory care

Question 2. Do you think some physiotherapy specialties carry more potential risk of transmission than others? Please rate on a scale 0-4, putting highest rlsk at 4.

Respondents rated respiratory care as highest: risk 4- 7 (28%), risk 3-5 (20%), risk 2-6 (24%), risk 1-6 (24%), risk 0-1 (4%) - see figure 3. Only one other speciality, obstetrics and gynaecology, was given risk 4 by one respondent (4%). Many areas were seen as risk 0: orthopaedics (27%), out-patient rehabilitation (50%), hydrotherapy (56%), neuromedicine (56%) and obstetrics and gynaecology (44%). One respondent said hand surgery ‘drastically increased’ risk of transmission in out-patient rehabilitation. Another based her answers on ‘being bitten or bled on’. Another thought confused or potentially aggressive patients increased risk transmission, but mode of transmission was not identified.

Question 3. Are there any specific cllnicai situations where a physiotherapist Is at risk from HIV transmission in her/his work? Of the respondents, 22 (85%) stated that specific clinical situations posed a risk. One (4%) did not know and two (8%) said none did.

Respondents were asked to describe such situations in detail: 18 (82%) directly or indirectly implicated blood and body fluids, whereas 4 (18%) referred to specialties or work practices, ie ITU, acute respiratory care, haemophilia treatment and suction. One (5%) raised being bitten and being coughed on by patients as presenting a risk, and 6 (23%) detailed a specific route of transmission, such as spilt blood on to cut hand.

Questlon 4. From your current knowledge, do the following fluids have the potential to transmit HIV blood, cerebro- spinal fluid, sputum, amniotic fluid, synovlal fluid, sweat? Yes, no, don’t know.

All 27 respondents gave blood as a risk, but other fluids drew a variety of responses (fig 4). The areas of uncertainty are highlighted in figure 5.

Question 5. In terms of personal rlsk, do you think you have a right to know your patients’ HIV status? - Yes, no, don’t know. Twenty (77%) said ‘yes’, and 6 (23%) said ‘no’. There were no ‘don’t knows’. All respondents explained their answers. Of those answering ‘yes’, 10 (50%) said they needed to know in order to take the necessary precautions and one of this group stated ‘although you should take the same

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Body fluids fluid fluid

Fig 4: Respondents’ perceptlon of risk of HIV tmnrmlulon from various body fluids

B Body fluids

Fig 5: Respondents’ uncertainty about the potmtlal of vlrlouc body fluids to transmit HIV

precautions with all patients’. Two (10%) said they wanted to know of any transmittable diseases; 1 (5%) said ‘correct nursing procedures’ could not be followed without the knowledge; one mentioned ‘the potential need to be more cautious’; and one felt knowledge of HIV status was useful with specific patients, eg violent onea

Of the 23% who answered ‘no’, all indicated that precautions should be taken with all patients, thw avoiding the need to know. One respondent added that HIV status should be viewed as medical not social history, and its implications for general health am important.

Questlon 6. Would youldo you have any anxietkr rboul personal risk If you knew/know your patient to be HIV+? - Yes, no, don’t know.

Nineteen (70%) said ‘no’, 7 (26%) said ‘yes’ and 1 (4%) did

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not know. On invitation to comment, 58% (15) did so. Of these, 6 (40%) felt no anxiety because precautions could be taken to ensure safety, 1 (7%) said she would ‘think twice’ about resuscitation, one wanted to be ‘more aware’; one had treated HIV+ patients without risk; and one believed that she could be more sensitive to patients if she knew. Another was concerned about prejudice towards patients and one said that HIV presented no more anxiety than hepatitis B or tuberculosis. The respondent who did not know about her anxieties was unsure about her feelings when faced with the actual situation. Questlon 7 (for respondents who answered ‘yes’ or ‘don’t know’ to questlon 6). Would you be reassured by HIWAIDS gulde llnes for physlotheraplsts In cllnlcal practlce?

Of the 8 (30%) who expressed anxieties or were unsure, all would be reassured by specific guide lines for physiotherapists. One added that much about HIV is still unknown. Another welcomed any information on all infectious diseases. Guide lines were thought appropriate by senior I (13%), senior I1 (50%) and junior staff (37%).

Questlon 8 (for respondents who answered ‘no’ to questlon 6). Dld you answer ‘no’ to questlon 6 because you feel fully confldent about pmtectlng yourself and your patients from HIV transmlsalon In your cllnlcal practlce?

The 70% with no anxieties expressed total confidence in preventing transmission when treating a known HIV+ patient.

Summary of Results .Physiotherapists perceive the profession as presenting a low risk of HIV transmission in comparison to some other medical professions. An hierarchy of risk among professions was clearly identified with no clear consensus about risk distribution. .There is an need for guide lines specific to physiotherapy, identified by both basic and senior grade staff, and substantiated by the variance in knowledge base, confidence levels and the perceived ability to deal with HIV. .A wide range of risk between specialties was perceived, with no clear consensus about risk distribution. A large number of respondents gave certain areas a zero risk rating. .A range of clinical situations was perceived as posing potential risk. .Knowledge about risky body fluids was incomplete. .The majority felt they had a right to know patients’ HIV status. .The majority felt confident treating known HIV+ patients. .Only a small percentage felt confident treating a patient without knowledge of status.

Other findings are dealt with in the ‘Discussion’.

Discussion HIV Risk for Health Care Workers As has been stated in the introduction, it is known that health care workers are at occupational risk of HIV. It is commonly understood that needlestick injuries or cuts

involving exposure to blood present the highest risk and that other exposures are less risky (Hughes, 1989). Puro and colleagues (1990) studied accidental blood exposures and found that skin and mucous membrane exposures accounted for only 7.5%. Marcus (1988) found open wound contamination and mucous membrane exposure accounted for 12% of exposures. The seroconversion rate for needlestick injuries is estimated to be extremely low (0.36% in Stock et al, 1990; less than 1% in Shanson, 1988; 0.5% in Henderson, 1988). Furthermore, Stock et a1 (1990) put the risk of seroconversion after skin and mucous membrane exposure as virtually nil. In the current study, the potential clinical exposure described by respondents fitted entirely into the skin and mucous membrane category of risk.

It is interesting to note that Puro et a1 (1990) observed highest exposure risk in surgeons (0.001) and lowest in physicians (ie general practitioners - 0.00008). This correlates well with findings in this study where respondents thought general practice and physiotherapy were about equally risky.

These findings contrast with studies investigating how health workers themselves view transmission risk at work. Klimes et a1 (1989) included anxiety levels about HIV in a survey of doctors and nurses in which 24% expressed anxiety about infection, despite precautions. Smyser and colleagues (1990) surveyed emergency health professionals and 56.6% believed their chances of infection from HIV were ‘somewhat high’ or ‘very high’, despite the low number of documented seroconversions. In a hospital worker survey, Gordin et al(1987) found that 25% were extremely anxious about dealing with AIDS patients. Akinsanya and Rouse (1991) found that 33% of hospital nurses thought nurses and doctors caring for patients with AIDS ran a risk of infection. Lowey (1989) researched medical staffs perceptions of the risk of HIV in comparison to hepatitis B virus (HBV). Staff underestimated the risk of HBV and overestimated the risk of HIV. (For HBV risk, see CDC update, 1988.) Physiotherapists were not mentioned in any of these studies.

HIV Risk Within Physiotherapy Given that the health workers commonly thought to be most exposed to risk are nurses, phlebotomista (who take blood samples) and laboratory technicians (Hadley, 1989) and surgeons (Puro et al, 19901, the estimated risk to physiotherapists must indeed be extremely low. Most physiotherapists would have rare contact with needles, except those practising acupuncture, where there are stringent guide lines in force. Hence the perception of low risk within physiotherapy in this study appears correct.

Respiratory care was the area of greatest perceived risk within the profession. It is interesting to explore the reasons for this view. There are no documented cases of transmission via suction or sputum. Indeed the CDC guide lines (Centres for Disease Control, 1988) acknowledge infection control procedures adopted for endotracheal suction as minimising risk. These precautions have already been taken against other transmittable disease such as hepatitis B virus and tuberculosis, which are both carried in sputum. Why this

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high risk is seen is not clear. Perhaps it is based on potential contact with body fluids. It could also be related to incorrect knowledge of body fluids and transmission routes, which would inflate risk perception (see below). Another plausible reason would be the well-documented relatively high prevalence of respiratory complications in some AIDS patients, such as Pneurnocystis carinii pneumonia, which would increase physiotherapists’ contact with the disease It may be argued that regarding respiratory care as a high risk could detract from other risk perception. Many other specialties were largely rated as at no risk, possibly bearing out this statement. In addition, blanket zero ratings assume an immunity which may make precautions seem worthless and put people at risk. Added to the level of incomplete knowledge about body fluids, this is a potentially dangerous situation.

It was startling to see how high a risk rating dentistry had been given by respondents. Until the recent widely publicised case of three patients allegedly contracting the virus from a dentist, this risk had been thought very low (Laskaris, 1988; Sculley and Porter, 1991). It can be projected that media hype is responsible for artificially enlarging risk perception. It is intriguing to speculate on how one individual case of transmission within

. physiotherapy could change both health workers’ and the public’s perception of the profession’s risk potential. Bratteb and colleagues (1990) note that the attitude of health professionals towards the virus has a great influence on public opinion - an objective view needs to be maintained.

Body Fluids and Perceived Risk Questions about body fluids provided a direct way of assessing the accuracy of risk perception. Great discrepancy in knowledge was shown. The Centers for Disease Control (1988) state that blood, semen and vaginal secretions are known to transmit HIV. Other fluids, where the risk of transmission is unknown, and which are therefore regarded as potentially risky, are: cerebrospinal (CSF), synovial, peritoneal, pleural . and pericardial fluids. (HIV has been isolated from CSF, synovial and amniotic fluid, and one case of HIV transmission was reported from percutaneous exposure to bloody pleural fluid, via needle aspiration. But the fluid responsible is undetermined.)

Fluids listed as not presenting risk are sputum and sweat, along with faeces, nasal secretions, tears, urine and vomitus - unless they carry visible blood.

Using the above guide lines, the correct perception of risk in the study was as follows: blood (loo%), CSF (19%), sputum (52%), amniotic fluid (22%), synovial fluid (15%), sweat (85%). Respondents’ uncertainty was shown in figure 5 and incorrect assumptions are shown in figure 6.

This pinpoints a large margin of error and uncertainty among those surveyed; risk from body fluids is both over- and under-rated and this clearly will affect perceptions of risk in clinical practice. For example, as suggested above, the perceptions about sputum may explain the high risk given to respiratory care, but these could not be correlated because blood-stained sputum provides a confounding variable These findings clearly demonstrate

Fig 6: Respondents’ Incomct assumptions about the potential of various body fluids to transmit HiV

a need for information about body fluids and risk, so that transmission potential can be more accurately assessed.

Assessing the Risk The presence of blood in other fluids was raised by many respondents. In weighing up the risk of blood-stained body fluids, it is necessary to consider the following: lb ensure the survival of the virus, certain conditions must prevail: body temperature (37”C), a moist environment and a slightly alkaline pH. For trans- mission to occur, the virus must be intact, must be in a large enough quantity, and a suitable route into the body, such as a cut on an uncovered hand, must be available. Route of transmission is a key issue in assessing HIV risk. A large amount of risky body fluids represents no danger if entry into the body is blocked. The small percentage of respondents who detailed clear routes was disappointing. However, no conclusions about knowledge levels can be drawn from this, as the survey was not intended to test knowledge.

Bearing these factors in mind, one can speculate on the poor transmission potential of some fluids, including blood-stained ones, in a clinical situation. This is not to say that there is no risk, but it has to be put into perspective. The fundamental reference point is that there are no known cases of such transmission and widespread precautions are already taken because of other transmittable diseases such as hepatitis B and tuberculosis.

HIV Patient Status and the Right to Know Knowing patients’ HIV status is a topic of great controversy, particularly in the USA where some health consumers want the right to know the status of health workers. AIDS activists insist that the prescribed use of universal precautions pre-empts this ‘need to know’. The question in the current survey was aimed at contrib- uting to this debate. It may be speculated that this question more accurately reflects risk perception, as it presents a specific clinical situation.

A high percentage of physiotherapists surveyed (77%)

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felt they had a right to know HIV status, compared to 57% in Akinsanya and Rouse (1991). Half ofthese wanted to know in order to ensure the necessary precautions are taken. Implicit in this finding are observations about precautions. It implies that some of the physiotherapists surveyed either do not support or do not understand the policy underlying universal precautions. It hints at the possibility that precautions may be used only intermittently, depending on the known or suspected status of patients. (Research has shown that precautions are not universally applied. For example, Smyser and colleagues (1990) showed that only 37% of emergency medical professionals reported always using gloves when treating bleeding patients.) This finding is further supported by the fact that large proportion of those wanting to know status correlated highly with those who felt confident treating known HIV+ patients (77%). Of these 60% expressed confidence in their treatment techniques. This finding shows that the need to know was motivated by fear of the unknown and that the anxiety was not a reflection of their ability to apply precautions. It indicates a strong correlation between knowledge and confidence.

This contrasts to the 23% who did not want to know and who all expressed total confidence in treatment using precautions. It is the author’s opinion that if universal precautions were taken, there h u l d be no need to know for protection purposes. Certain respondents felt that status details had implications for general health care. But the health workers’ needs have to be set against the patients’ right to confidentiality. Wanting to know also suggests that HIV is a known factor in health care But the number of asymptomatic individuals is increasing, and many are unaware of their positive status. As Beasley (1990) states: ‘Therefore it is important that all nursing personnel take reasonable precautions against exposure to blood and certain body fluids from all patients, in all departments, all of the time, regardless of what is or is not known regarding their serological status in relation to HTV infection’.

Until this is understood and acted upon, the actual risk within the physiotherapy profession may be larger than perceived, and, importantly, larger than necessary. The problem may be that low risk-perception leads to unnecessary risk-taking.

Who Poses a Risk? Throughout the questionnaire, the source of the risk was not specified. The majority referred to protection from the patient. Only one respondent implied that patients needed protection, although it was not clear if this was protection from physiotherapists or from other patients. No respondent suggested that she might pose a risk to patients. If semonversion increases a t the widely predicted rate, physiotherapists need a greater awareness of their potential risk to patients.

The Need for Guide Lines Only those who expressed anxieties about treating HlV+ patients were asked if guide lines were needed. This was in order to identify actual need rather than elicit a general welcome. This need was clearly identified

among the ‘anxious’, who represented all grades of staff except superintendents.

It must be emphasised that for those lacking confidence, guide lines are not enough. Training must be given to improve understanding and practice. The effectiveness of such education was established in the study by Flaskerud et a2 (1989) which showed significant pre- and post-test differences in knowledge and attitudes about HIV/AIDS among nurses. It is very positive that the majority of physiotherapists felt confident in treating a known HIV+ patient. However, with the unsatisfactory knowledge base, ’ some of this confidence may be misplaced. There was no evidence that treatment would be declined, although surveys among other medical professions have revealed otherwise (&din et al, 1987; Akinsanya and Rouse, 1991; Klimes et al, 1989). However, this issue was not addressed specifically, with responses being limited to ‘comments’, so this observation is not conclusive. Ethical obligations about treatment are clearly outlined in the CSP’s Rules of Professional Conduct and specific issues relating to HIV/AIDS are discussed in several articles (Sim and Purtilo, 1991; Sim, 1991).

Limitations Finally, a few comments about the method: The high response rate reflects the success of the chosen method, and may also indicate the importance given to the issue An additional influential factor may have been the support of the superintendent. A confusing variable that was considered was the possibility that the respondents would fill the questionnaires in together and thus be influenced by others’ opinions and experience. However, without undue supervision, this could not be ruled out. It is also recognised that choosing a low-prevalence area and a hospital with no HIV specialism may have influenced outcome. Finally, the pitfalls of questionnaires are well documented Cl’reece and Treece, 19861, in particular that respondents are better able to express their thoughts in speech than writing. Additionally, the scale of risk could have been further clarified by stating ‘0 = no risk’. It would have also been useful to insert a ‘don’t know’ option in both questions 1 and 2, as some respondents left occasional answers blank. It is unclear whether this is due to system error or simply inability to answer. The same two questions also needed clarification about universal precautions, since two respondents assumed their use and therefore rated all sections of both questions risk 0 or 1. This highlighted a flaw in the questionnaire and obviously affected results. Hence all findings are subject to the limitations of the method.

Conclusions and Recommendations The study achieved its aim of exploring physiotherapiste’ perceptions of HIV transmission in clinical practice It also provides a valuable insight into physiotherapists’ current anxieties and revealed a wide discrepancy in both risk perception and knowledge base

A low perception of risk of HIV transmission within physiotherapy appears to be correct. However, this low risk should not justify the current low profile of

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HIV awareness in the profession. Physiotherapists have a key role to play in caring for people with HIV illness, and as the virus spreads, this role will increase. But both the low profile and the low risk perception run the danger of lulling the profession into a false sense of security. Although no documented cases of transmission within physiotherapy exist, the profession still needs to ensure that its current frame of reference encompasses the issues which HIV and AIDS raise and are likely to raise. For example, personnel issues such as.disclosure of a staff member’s HIV+ status or a staff member’s refusal to treat an HIV+ patient will need sensitive and clear guide lines. An ethical issue such as a breach of confidentiality also requires clear guidance Providing information would have other bonuses. It would raise HIV as an issue for physio- therapists and would hopefully promote discussion. It would highlight individual and departmental training needs and thus give some structure to training policies. As a result of training, staff anxiety levels would decrease and confidence levels would increase, Professional practice would improve as a consequence. Last but not least, it is vital that physiotherapists, in line with other health workers, are able to respond pro-actively to an issue which represents such a risk to public health.

The following recommendations support the study’s secondary aim of generating ideas for further action and research:

1. All pre-registration courses should include education on the social and clinical aspects of HIV and AIDS, with specific reference to universal precautions and body fluids, to ensure students are fully prepared for clinical placements, and for post-registration experience 2. HIV guide lines specific to physiotherapy should be formulated by the CSP or another appropriate body, in collaboration with physiotherapists and other medical staff working in the HIV field. Personnel issues should be included. 3. These guide lines should be widely distributed and subsequently available as part of the CSP’s range of publications. 4. Nominations should be sought from physiotherapists offering to act as a source of information and support on HIV issues. 5. The setting up of a Specific Interest Group related b HIV should be considered. 6. The Rules of Professional Conduct should be reviewed to ensure that all HIV issues are adequately covered. 7. Physiotherapy departments should be committed to provide up-to-date ongoing education on HIV to all staff, including helpers. 8. More research should be undertaken. The current study points to other useful areas of focus: a follow-up study using interview techniques to explore the issues raised; to compare the risk perceptions of HIV of other health workers such as surgeons and occupational therapists, with those of physiotherapists; to compare risk perception of those directly working in the HIV field and those not specifically involved; a two-centre study in areas of high and low HIV prevalence to compare differences in risk perception; to compare risk perception

between staff with HIV training and those without; to compare levels of risk perception pre- and post-training and to determine its effectiveness; to explore perceptions of respiratory care as a higher risk, with a view to providing appropriate training; to survey attitudes of physiotherapists to universal precautions; and to survey use of universal precautions in physiotherapy. It is important that the training needs identified as a result of this research should be met as soon as possible.

Acknowledgments Many thanks to the superintendent physiotherapist who supported this project and freely gave her help. Many thanks also to Julia Him, lecturer in health education with specific reference to HIV and AIDS at Sheffield Hallam University, for her clarity and vision. This research paper was undertaken as part of the final examination of the bachelor of science degree in physiotherapy at Sheffield Hallam University, June 1992.

Author and Addmss for Comspondence Lesley Dike BSc MCSP is a staff physiotherapist, Rotherham District General Hospital, Moorgate Road, Oakwood. Rotherham. South Yorkhire S60 2UD.

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Shanson , D C (1988). ‘Controversies about guide lines to prevent the transmission of human immunodeficiency virus in hospitals in Britain’, Journal of Hospital Infection, 11, suppl A, 218-222. Sim, J (1991). ‘AIDS and occu ational risk: An ethical challenge for physical therapy’, presente8at World AIDS conference, August 1991. Unpublished.

Sim, J and Purtilo, J (1991). ‘An ethical analysis of physical therapists, duty to treat persons who have AIDS: Homosexual patients as a test case’, Physical Therapy, ’H, 9, 650-654. Smyser, M S, Bryce, J and Joseph, J G (1990). ‘AIDS-related knowledge, attitudes and precautionary behaviours among emergency medical professionals’, Public Heelth Reports - Hyamville, 105, 5, 496-504. Stock, S R, Gafni, A and Bloch, R F (1990). ‘Universal precautions to prevent HIV transmission to health care workers: An economic analysis’, Canadian Medid Arwociatlon Journal, 142,9,937-946 Stone, S (1991). ‘Qualiihre research methods for physiotherapists’, Physiotherapy, 77, 7, 449-452. Treece, E W, and Peece, J W (1986). Elements of Research in Nursing, C V Mosby, Philadelphia, USA, 277-278. United States Department of Health and Human Services (1987). ‘Recommendations for prevention of HIV transmission in health care settings’, Reproduced from Centres for Disease Control Morbidity and Mortality Weekly Report, suppl 36, 2s.

At Home At Home, Fmpost, Leyburn, North Wkahlre DL8 48s. A4. Quarterly 12 pages. F m .

Formally presented by calling Itself a newsletter, and sponsored by Unicare Medical Services Ud, this periodical states that it is for ‘homecare therapy initiatives’. It carries articles on subjects such as artificial nutrition, major charities, com- plementary therapies, and the politics of shared care. There is a wealth of facts and figures, and plenty of information On costings and the practicalities of organising various kinds of care.

Eumpean Rehabilltation Newsletter Dr A Cut& 36 Clarendon Road, Leeds LS2 9NZ. A4. ’livice-yearly 6 pages. F m . Started 1992.

The first issue of this newsletter was distributed to more than 1,OOO profes- sionals working in all branches of rehabili- tation throughout Europe. It aims to provide items of interest to everyone - rather a tall order since only four of the pages are devoted to text; the rest carry a calendar of coming events. Features cover subjects such as rehabilitation engineering at Brunel University and research into and care for brain damaged patients in the Netherlands and South Derbyshire.

Dlsablllty, Pregnancy and Parenthood lnternatlonal Arrowhead Publications, 51 Thames Village, London W4 3UE Quarterly. 16 pages. f20 pa. Started January 1993.

A forum for disabled parents and the professionais helping them, which aims to share information and experience to the benefit of other people with disabilities who may suffer from ignorance or prejudice in raising children. The first issue carries articles about programmes for disabled

parents in British Columbia and California, parentcraft classes for visually impaired people, articles for midwhres and expectant mothers, and an account of personal experience.

Health Manpower Management MCB University Press Ltd, &I432 Tdler Lane, Bradford BDB 9BY. Quartew. f 129 pa.

This journal focuses on human resource issues within the health care industry, covering topics such as forecasting manpower requirements, equal opp- ortunities, industrial relations, training and development. Recent articles have dealt with staff stress, child care, assessment, and management of change.

Hygela European Foundation for the Improvement of Living and M l n g Conditions, Loughllnmwn House, Shankill, Co Dublin, Ireland. Produced during the Eutcpean )gar of Sam, Hygiene and Protection at M r k , 199,993 4 pages. Free.

Each issue carries a main article on a specific topic, such as workplace action for health, design of buildings and equipment, or health and safety. This is followed by news from member States about their efforts to improve working conditions. The twocolour layout is attractive and readable.

Vldeoservlce Videos lnternatlonal on Disability. Equal Opportunities and Society, 4424 Forman Avenue, Toluca Lake, Callfornia 91602, USA. Quarterly Started December 1992. 12 pages. Individuals W, libraries $75

The purpose of this newsletter is to show how the mass media are portraying disability issues and to encourage media decision-makers to be more progressive and fair in their coverage of people with

disabllities. The first issue contains success stories about people with handicaps, news about film festivals, and reviews of films and US television programmes.

Healthcare Management Medicom (UY Ltd, The Quadrant, 118 London Road, Kingston upon Thames, Surrey KT2 tW. Monthly. Started January 1993 58 pages.

Glossy full-colour publication for con- sultants and senior managers. Articles cover medical staffing and training, accounting and marketing, management Issues such as restricting smoking and reducing liability claims, and provision of alternative therapies.

Target NHS Publicity Services, Wellington House, 135155 Waterbo Road, London SE1 BUG. A4. Quarterly. 6 pages (tripfych). Started December 1992.

Intended to draw together and build on the goodwill and expertise generated by ‘The Health of the Nation’ White Paper this newsletter focuses on groups and organisations working together.

Highly coloured and readable, it features initiatives In various areas such as health promotion in the workplace, prevention of smoking, and the use of leisure centres to encourage exercise programmes, organised mainly by local authorities and the voluntary sector.

NLB News National Library for the Blind, Cromwll Road, Bredbury, Stockport SK6 2SG. Three times a year Started December 1992. 8 pages. Free.

A largeprint newsletter for clients of the National Library for the Blind, which has just celebrated its 11OthMrthday. It contains news about the extension to its building opened last autumn, the work carried out there, and - naturally - information about stocks and new additions to the books available.

Phydotherapy, March 1993, vol79, no 3