WORK A Journal of Prevention, Assessment & Rehabilitation

ELSEVIER

Work 5 (1995) 301-310

Knowledge about AIDS and attitudes towards persons with AIDS: Implications for occupational therapy Gayle B. Lang* Boston University, Boston, MA 02115, USA Received 26 April 1995; accepted 25 May 1995

Abstract

Persons with acquired immunodeficiency syndrome (AIDS) are frequent users of healthcare services, and their care presents a critical challenge to the healthcare profession. With an estimated one million persons in the United States believed to be infected, occupational therapy practitioners will see increasing numbers of referrals to provide services to persons with AIDS. Like other healthcare professionals, occupational therapy practitioners have expressed inaccurate knowledge about AIDS and negative attitudes towards persons with AIDS, both affecting the therapeutic relationship, and possibly leading to suboptimal clinical care. This paper summarizes research that measures healthcare professionals' knowledge and attitudes about AIDS. It also explores the effectiveness of educational programs aimed at increasing knowledge about AIDS and modifying attitudes towards persons with AIDS. Further research is proposed in the occupational therapy field to assist in the development of educational programs addressing these important AIDS issues.

Keywords: Education; Ethics; Healthcare; Human immunodeficiency virus (HIV)

1. Introduction

Almost 500000 people in the United States have been diagnosed with Acquired Immunodeficiency Syndrome (AIDS) since it was first reported by the Centers for Disease Control in 1981 (CDC, 1995). In 1994, 80691 new AIDS cases *Address for correspondence, 47, Fenwood Road, Boston, MA 02115, USA Tel.: + 1 617 7384787.

were reported in the United States, and AIDS is currently the leading cause of death among Americans between the ages of 25 and 44. With over one million more Americans believed to be infected and no cure in sight, AIDS will remain a critical public health problem into the 21st century (Angell, 1991). AIDS is caused by the human immunodeficiency virus (HIV), and is characterized by severe immune deficiency leaving the infected person vulnerable to opportunistic infections and malig-

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nancies. Life-threatening diseases associated with AIDS include: pneumocystis carnii pneumonia, toxoplasmosis, cytomegalovirus, Kaposi's sarcoma, and cryptococcal meningitis (Scussel, 1989; Daniel and Strickland, 1992). In addition, AIDS is marked by medical complications such as peripheral neuropathy, AIDS dementia complex, transient ischemic attack, respiratory distress, as well as generalized fatigue, weakness and deconditioning (Strax, 1995). Persons with AIDS also frequently experience psychosocial problems such as depression, anxiety, stress, isolation and fear of death. Unfortunately, the treatment of persons with AIDS exceeds the mere management of physical and psychological sequela of the disease. Societal fears and prejudice towards persons with AIDS have combined to further stigmatize a patient group already facing an upward battle against a terminal disease. In a review of the prevailing attitudes in society towards persons with AIDS, Okoli and King (1993) report, 'people's attitudes are not just towards the virus or the disease, but also towards the groups of people affected and the means by which they became infected' (p. 168). Because AIDS was initially reported to affect only homosexuals, drug-abusers and Haitians, negative attitudes and prejudice towards members of these groups has become associated with the AIDS diagnosis. In addition, the association of AIDS transmission with homosexual sex and intravenous drug use has led to the erroneous conclusion that AIDS is a moral - rather than medical - issue. Rather than viewed with compassion, persons with AIDS are blamed for their condition. Even within the healthcare community, negative attitudes exist towards persons with AIDS and members of groups at a high risk of developing AIDS (van Servellen, Lewis and Leake, 1988, 1990; All, 1989; Gerbert, Maguire, Badner, Altman and Stone, 1989; Pomerance and Shields, 1989; Simon, Weyant, Asabigi, Zucker and Koopman, 1991; Dike, 1993). The inappropriate attitudes of healthcare workers have been reported to affect their interactions with patient groups at a high risk of AIDS, leading to suboptimal clinical care (King, 1989). Coupled with negative atti-

tudes, healthcare workers often possess inaccurate knowledge about AIDS. In particular, uncertainties regarding modes of transmission of AIDS have led to an unwarranted fear of persons with AIDS in the hospital setting (Atchison, Beard and Lester, 1990). Because persons with AIDS are frequent users of healthcare services, issues of inaccurate knowledge, prejudice, and negative attitudes must be addressed within the healthcare community, including occupational therapy personnel who frequently provide services to persons with AIDS. Given the spectrum of illness and disability associated with AIDS, many persons with AIDS are referred to occupational therapy (OT) at various points throughout the disease course. Occupational therapy intervention is compensatory in nature, aimed at reducing physical and psychosocial impairments and prolonging independent function for as long as possible. 'For many people with HIV, occupational therapy is a vital service that increases their level of independence, facilitates their psychological adjustment to the disease process, and improves their quality of life' (Scussel, 1989, p. 803). Like other healthcare professionals, occupational therapy personnel have expressed fear and anxiety about persons with AIDS, inaccurate knowledge of AIDS and its transmission, and negative attitudes towards persons with AIDS (Atchison et aI., 1990; Vincent and Schkade, 1990). Occupational therapy practitioners have a clear professional and ethical responsibility, grounded in the Occupational Therapy Code of Ethics, to provide services to persons with AIDS (AOTA, 1994). Thus, it is essential that the profession ensures that its practitioners are prepared to provide competent and appropriate services to persons with AIDS. Educational efforts must be designed to increase OT practitioners' knowledge about AIDS, as well as to modify attitudes towards persons with AIDS. This paper summarizes research which measures healthcare professionals' knowledge and attitudes about AIDS. In addition, research which measures the effectiveness of various educational programs in increasing knowledge and modifying

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attitudes will be examined. The following questions will be addressed: What is the extent of healthcare workers and students' knowledge about AIDS, and what attitudes do they possess towards persons with AIDS? Are educational programs for healthcare students effective in both increasing knowledge about AIDS and modifying attitudes towards persons with AIDS? A systematic review of the research relevant to these questions has not yet been undertaken in the occupational therapy literature. Given that limited occupational therapy research has been done, this paper will focus on research in other healthcare disciplines, applying those findings to the practice of occupational therapy. In addition, recommendations for further research in the occupational therapy field will be proposed, with the aim of modifying OT educational curricula to include broader AIDS issues. Understanding how educational programs may affect occupational therapy practitioners' knowledge and attitudes about AIDS will assist in the development of OT educational programs, which will in tum enable occupational therapy practitioners to provide appropriate and effective services to persons with AIDS. 2. Healthcare personnel and students' knowledge and attitudes Healthcare professionals choose to enter a career of sickness. Thus, it seems antithetical that inaccurate knowledge about AIDS and negative attitudes towards people with AIDS exists among professionals who have chosen to treat the sick. Numerous studies, however, have reported that such negative attitudes, fears, and inaccurate knowledge about AIDS are prevalent among healthcare workers and students, affecting their willingness to care for people with AIDS (van Servellen et aI., 1988, 1990; All, 1989; Gerbert et aI., 1989; Pomerance and Shields, 1989; Simon et aI., 1991; Dike, 1993). In a 1988 study, van Servellen et al. measured knowledge about AIDS among nurses practising in California. Of the 1019 nurses polled, only 11.9% correctly identified key symptoms indicative of early stages of AIDS. Moreover, only 4.7%

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were able to identify groups at both high and low risk for contracting AIDS. In routine assessments of patients, only 8.7% of nurses reported taking a sexual history to ascertain a patient's risk of exposure to AIDS. Given that California had the second highest incidence of AIDS in 1988, such low knowledge scores are surpnsmg in nurses who had a relatively high exposure to persons with AIDS. The van Servellen survey (1988) also measured nurses' fears and attitudes towards persons with AIDS. A quarter of nurses surveyed believed they had a moderate to high risk of contracting AIDS in the workplace. In caring for male homosexuals, not necessarily those known to have AIDS, 38.4% admitted a moderate to great deal of discomfort. Most strikingly, 23.1% of nurses polled indicated they would absolutely not accept a job caring for patients with AIDS, and 53.6% believed nurses should have the right to refuse caring for patients known or suspected of having AIDS. Nurses are not the only healthcare professionals to have reported inaccurate knowledge and negative personal reactions in their work-related experience with people with AIDS. Pomerance and Shields (1989) surveyed employees from 13 different hospital departments who had work-related experience with persons with AIDS. Over one-third (35%) of the 256 respondents to the survey reported feeling at high risk when caring for persons with AIDS, and 40% reported feelings of high stress and discomfort. Pomerance and Shields (1989) attempted to explain these employees' perceptions of risk, stress, and discomfort by examining demographic variables, occupational status, degree of knowledge about the transmission of AIDS, degree of contact with persons with AIDS, and the social psychological variables of death, anxiety and homophobia. Results of multivariate analyses indicated that while nurses felt higher levels of risk when working with persons with AIDS, doctors reported feelings of high stress and discomfort. Social workers reported the lowest levels of stress, risk and discomfort. Regardless of occupational status, the degree of contact with persons with AIDS was positively correlated to all three variables - perceived stress, risk and comfort.

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Workers who had greater contact with persons with AIDS felt higher levels of comfort, but also felt high levels of stress and perceived risk. Unfortunately, the authors did not sub-divide workrelated contact into narrower categories. Had this variable been further divided into invasive clinical contact and social interaction contact, the results would have helped determine if the stress, risk, and discomfort levels correlated with an actual increase in potential exposure to AIDS (invasive contact), rather than a perceived increase in exposure (social contact). Pomerance and Shields (1989) also found knowledge of AIDS transmission to be related to all three outcome variables. Workers with more knowledge on AIDS reported lower levels of perceived stress and risk, and higher levels of comfort in caring for persons with AIDS than those with less knowledge. Likewise, homophobia was directly related to all three variables. Workers who reported negative attitudes toward homosexuality reported higher levels of perceived risk and stress, and lower levels of comfort. Homophobic feelings were prevalent in this sample - over 50% agreed with the statement, 'I find the thought of homosexual acts disgusting.' A study by Simon et a1. (1991) built upon the work of Pomerance and Shields (1989) in attempting to find a correlation between .knowledge and / or attitudes and willingness to treat persons with AIDS. The authors correlated first and second-year medical students' intention to treat persons with AIDS with five variables - knowledge of AIDS transmission, comfort in performing a physical examination on patients from high-prevalence populations, level of homophobia, perceived risk of infection, and professional responsibility. Overall, 57% of the 201 medical students studied reported a high intention to treat persons with AIDS. Nearly one in five students (19.6%), however, indicated that they would prefer to have 'somebody else' take care of a person with AIDS. Results of two-way analysis indicate that all variables, with the exception of perceived risk, were significantly associated with intention to treat persons with AIDS. Students with high knowledge, comfort, and professionalism, and low homophobia, were most likely to have a high intention to treat persons with AIDS, although knowledge

showed the weakest relationship with the intention to treat variable. These results contrast with those of Pomerance and Shields (1989), who found among healthcare workers a significant positive correlation between increased knowledge and perceived comfort, and a negative correlation between increased knowledge and perceived risk and stress. But both studies showed significant relationships between levels of homophobia and the measured variable(s) of intention to treat persons with AIDS, or perceived stress, risk and comfort in working with persons with AIDS, adding credence to the suggestion to incorporate both knowledgebased and values-based education in AIDS education programs for healthcare students. The results of the studies discussed previously emphasize the importance of both didactic education about AIDS, and values clarification education regarding homosexuality, as a means to lower healthcare workers' levels of stress, risk, and discomfort in working with persons with AIDS. These two studies, however, measured only the correlation of knowledge and attitudes to willingness to treat persons with AIDS, and did not attempt to demonstrate a causal relationship. Still, correlation studies have served to identify specific knowledge and attitude areas to be included in studies which measure the effectiveness of educational programs (discussed in a later section). Without the information gained from correlational studies, the conclusion might be incorrectly drawn that knowledge about AIDS is the only factor in determining a healthcare worker's willingness to care for persons with AIDS, and therefore that educational efforts should focus primarily on increasing knowledge about AIDS among healthcare students. Through these correlational studies, however, we have learned that several other factors - in addition to knowledge - affect the willingness of healthcare workers to care for persons with AIDS. 3. Occupational therapy practitioners and students' knowledge and attitudes Only three studies to date in the occupational therapy literature have looked at knowledge about AIDS and attitudes towards persons with AIDS

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among occupational therapy practitioners and students (Atchison, Beard and Lester, 1990; Vincent and Schkade, 1990; Falk-Kessler, Barnowski and Salvant, 1994). As with other healthcare workers, negative attitudes, fears and inaccurate knowledge about AIDS existed among OT practitioners and students. Atchison et al. (1990) conducted a survey of 119 occupational therapy practitioners working in various clinical settings in the Midwest. Of the sample, 45% reported previous experience caring for a person with AIDS. Knowledge about AIDS varied greatly among those surveyed, with the number of correct answers ranging from one to nine of the total 11 knowledge items. In addition, 'don't know' responses for individual questions ranged from 10 to 47%. Most disturbingly, almost half (45%) of the OT practitioners identified the media rather than professional education programs, as their primary source of information about AIDS. These results indicate a critical need for factual education about AIDS among occupational therapy practitioners. Atchison et al. (1990) also measured fear of AIDS in the work setting, and found that 36% of occupational therapy practitioners were afraid that they would contract AIDS in the routine care of a person with AIDS. Not knowing a patient's AIDS status was identified by 30% as their greatest fear about AIDS in the workplace. The attitudes of the OT practitioners towards persons with AIDS were inconsistent. While 86% of respondents agreed that persons with AIDS were entitled to the same care as any other patient, only 51% would be willing to provide that care. Similarly, while 85% of occupational therapy practitioners felt they should be informed of a patient's HIV-status, only 45% would apply that same standard to themselves as healthcare workers. These results suggest a need for both factual and attitude-based educational programs for occupational therapy practitioners. It should also be noted that in the Atchison et al. study (1990), a high percentage of the respondents (up to 43%) remained neutral on any given question in the fears and attitudes section of the survey. This suggests that occupational therapy practitioners may not have been given an adequate opportunity

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to explore their fears and attitudes about AIDS in an educational setting. Like the correlational studies discussed in the previous section, this study attempted to identify a correlation between respondents' level of knowledge about AIDS and willingness to care for persons with AIDS. No such correlation was found, again pointing to the need for more than just knowledge-based education in addressing healthcare workers' willingness to care for persons with AIDS. Atchison et al. (1990) did find a positive relationship between respondents' experience with persons with AIDS and willingness to care, suggesting the possible value of incorporating exposure to persons with AIDS into the occupational therapy curricula. In another study from the occupational therapy literature, Vincent and Schkade (1990) measured knowledge about AIDS and attitudes towards persons with AIDS among 36 occupational therapy students. Their knowledge and attitudes were compared to those of 33 education students, in an attempt to identify areas of change needed within the occupational therapy curricula. The authors purposefully did not look for a correlation between the two constructs of knowledge and attitudes, believing both to be important areas to address within occupational therapy education. Contrary to the authors' hypothesis that occupational therapy students would have more knowledge about AIDS than students in a nonhealth field, no significant difference in knowledge was found between the two groups. Moreover, in one instance, the authors found that more OT students (13%) than education students (6%) believed that AIDS could be transmitted via shared eating utensils. As in the Atchison et al. study (1990), Vincent and Schkade (1990) found that the media played a major role in 'educating' students about AIDS. Seventy-nine percent of respondents (in both groups) obtained their information about AIDS from the media, versus only 5% who reported receiving information from classes and seminars. The vast majority (92%) of occupational therapy students polled expressed a need for more information regarding AIDS. The authors also had hypothesized that occupational therapy students would have a more favorable attitude towards people with AIDS than

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education students. Upon analysis, two attitude measures yielded significant, yet contrary, results. Occupational therapy students demonstrated more disagreement with the idea that persons with AIDS should be quarantined (OT students, 72%; education students, 55%), lending support to the hypothesis. On the other hand, occupational therapy students also indicated more agreement that healthcare workers have a right to refuse to treat persons with AIDS (OT students, 58%; education students, 45%). Thus, the results of this study did not support the authors' hypotheses regarding occupational therapy students' attitudes and knowledge about AIDS, suggesting a need for change in the occupational therapy curricula which would incorporate both knowledge and attitude constructs into AIDS education. The Atchison et al. and Vincent and Schkade studies were published in 1990. Obviously, in the past 5 years, knowledge about AIDS has likely increased within the scientific community, including the occupational therapy profession. Occupational therapy practitioners' attitudes towards persons with AIDS might also have improved since the Atchison, and Vincent and Schkade studies. Such a finding would be consistent with the results of Pomerance and Shields, who found a positive correlation between knowledge about AIDS and improved attitudes towards persons with AIDS. A recent study conducted by Falk-Kessler et al. (1994) suggests otherwise. One hundred eighteen directors of occupational therapy departments who host OT fieldwork students in all areas of the United States participated in this study. The majority (86.3%) of respondents had over 5 years experience in occupational therapy, and 77% had worked with persons with AIDS. The purpose of this study was to examine the policies and attitudes that guide administrative decisions currently being made in occupational therapy departments regarding such issues as mandatory testing for AIDS, attitudes on treating persons with AIDS, working with HIV-positive staff members and students, and the use of the CDC guidelines on universal precautions. Universal precautions, set forth by the Centers

for Disease Control in response to the AIDS crisis, are reportedly practised in 96% of occupational therapy departments polled. Although this statistic implies adequate knowledge regarding the transmission of AIDS and methods to protect both healthcare workers and patients, additional survey responses suggest otherwise. When entering the room of a patient with AIDS, 16% of occupational therapists would wear a gown and mask. Although a small percentage, it suggests an inappropriate overuse of universal precautions. In addition, over half of the respondents (58%) wear gloves when treating any person with AIDS, although some respondents did add correcting caveats such as 'only if there is an open lesion' or 'only if contacting a patient's mucous membranes.' In contrast, occupational therapy practitioners reported an under-use of universal precautions when working with patients with an unknown AIDS status. Only 50% wear gloves when treating a patient requiring a postoperative splint - a time when the risk of contact with open wounds is high. These findings suggest that precautionary measures are used in excess by occupational therapy practitioners concerned with exposure to patients known to have AIDS, and are not used adequately when a patient's AIDS status is unknown, thus exposing both the patient and the OT practitioner to risks of infection - AIDS or otherwise. Every respondent indicated they would treat a person with AIDS, even postoperatively, suggesting that persons with AIDS are receiving occupational therapy services. Eleven percent of those polled, however, stated that an occupational therapist has the right to refuse to treat persons with AIDS, in direct conflict with their profession's Code of Ethics (AOTA, 1994) and an HIV position paper (Scussel, 1989), both of which set forth a professional and ethical responsibility to provide occupational therapy services to persons with AIDS. For 11% of OT practitioners polled, those services are not thought of as a person with AIDS' right, but as treatment provided above and beyond their professional duty. In addition to providing the most up-to-date information about occupational therapy practi-

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tioners' knowledge and attitudes about AIDS, this study is important for two other reasons. The occupational therapists polled are all directors of their departments, and thus are in positions of leadership within the occupational therapy profession. In addition, the authors targeted only sites which host occupational therapy fieldwork students. The knowledge and attitudes of these respondents, therefore, may well affect those of future OT practitioners through the fieldwork supervision process. Hence, the Falk-Kessler et al. study (1994) contributes valuable information regarding the current knowledge and attitudes about AIDS within the occupational therapy profession. In addition, the results shed light on what knowledge and attitudes are possibly being passed on to future OT practitioners via role-modeling and mentorship during OT fieldwork supervision. 4. Educational programs for healthcare personnel and students

As discussed previously, healthcare workers and students often possess inaccurate knowledge about AIDS and negative attitudes towards persons with AIDS. Therefore, educational programs addressing both knowledge and attitudes may be useful in helping healthcare workers provide more competent and appropriate treatment to persons with AIDS. To date, no studies in the occupational therapy literature have addressed this issue. Several studies in other healthcare disciplines have attempted to measure whether education programs can increase healthcare workers' knowledge and modify their attitudes about AIDS (Flaskerud, Lewis and Shin, 1989; Johnson, Campbell, Toewe and Bell, 1990; Chng and Moore, 1991; Pederson, 1993). Flaskerud et al. (1989) measured the effect of a 1-day AIDS continuing education conference on the knowledge of 125 nurses practising in southern California. Pretest/post-test results indicated significant changes in measures of knowledge about AIDS. Follow-up studies showed that the nurses retained the increased knowledge 2 months later, suggesting that effects of the education program may be long-lasting. Further analysis of the knowledge measures revealed that of the total

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group, the greatest gains were made among nurses with lower pretest knowledge scores, indicating that the educational program was more useful for nurses with little initial knowledge of AIDS. Furthermore, Flaskerud found significant changes in attitude measures after the educational conference, and at the follow-up, indicating that the educational program had a positive impact on nurses' attitudes towards persons with AIDS. In a study by Johnson et al. (1990), a group of medical students who participated in a 6-hour AIDS education workshop demonstrated a significant increase in knowledge about AIDS, as opposed to a control group of medical students who did not participate in the workshop. As with the Flaskerud study (1989), the greatest increases in knowledge occurred in the subjects with low pretest knowledge scores. Of the 73 medical students who participated in the workshop, first-year students showed greater knowledge gains than second-year students who had previous coursework on AIDS. Unlike the Flaskerud study, Johnson found no significant differences between pretest and post-test attitude scores between students who had participated in the AIDS workshop and students who had not, indicating that the workshop had little impact on medical students' attitudes towards persons with AIDS. The differences in the teaching methods utilized in the two studies may explain the contrasting results with respect to changes in attitudes. The majority of Johnson's workshop consisted of didactic instruction about AIDS epidemiology, pathogenesis, transmission and treatment, with the final portion discussing ethical, moral, and religious issues relating to AIDS. The workshop appeared more focused on factual information about AIDS rather than on attitudinal issues, which may have led to greater increases in knowledge measures than attitude measures among participants. In contrast, the Flaskerud educational conference incorporated a variety of teaching methods, including lectures, discussion groups, question/answer sessions, and a variety of teaching media including audiovisuals and written educational materials. The varied educational format may have created an atmosphere conducive to

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discussing attitudinal issues, thus leading to the significant changes seen in participants' attitudes towards persons with AIDS. Unfortunately, the authors did not explore further what particular aspect of the program contributed to changing attitudes, nor did they employ a control group to assure that the program itself led to these changes, and not some outside factor. Other studies have specifically addressed what teaching methods are most effective in changing attitudes towards persons with AIDS (Chng and Moore, 1991; Pederson, 1993). Chng and Moore (1991) investigated the relationship between attitudes towards AIDS and homosexuality among 52 college students. A panel of homosexual speakers addressed topics such as gay and lesbian lifestyles, stereotypes and discrimination, and etiology of homosexuality, to give students accurate information about homosexuality. Panel members deliberately avoided discussion of AIDS, as the purpose of the study was to examine the link between homophobia and fear of AIDS. Results indicated that students' fear of AIDS was moderately correlated with homophobia, suggesting that AIDS is still associated with homosexuality, and thus fear of AIDS might be addressed by targeting students' attitudes towards homosexuality. The authors hypothesized that by addressing students' homophobia via the panel of speakers, their fear of AIDS would also be affected. No significant differences were found between the pretest and post-test measures, indicating that listening to the panel of homosexual speakers did not affect students' level of homophobia or fear of AIDS. The authors admit that long-ingrained attitudes towards lifestyles and sexuality cannot be significantly changed through one-time didactic educational panels. Recognizing the possible limitations of didactic education in addressing attitudinal changes, Pederson (1993) compared the effectiveness of two teaching methods in changing 51 nursing students' beliefs and attitudes towards persons with AIDS. In the control condition, students listened to a lecture on AIDS. In the treatment condition, students participated in an interactive teaching method known as structured controversy, in which small groups of students argue both for and

against a position, then attempt to reach consensus on the given issue (Johnson and Johnson, 1988). The controversial issue chosen for this study is whether a nurse has the right to refuse to treat a patient with AIDS. Immediately after the treatment or control condition, students completed a questionnaire measuring their intentions, attitudes, and beliefs about caring for persons with AIDS. Results indicated that students who had participated in the structured controversy showed somewhat higher levels of caring for persons with AIDS than students who had listened to the lecture on AIDS, although few of the results were significant. Because results of statistical tests did not strongly favor one educational approach, the author suggested that both teaching methods be incorporated into educational curricula on AIDS. Another limitation of the Pederson study is the lack of a pretest measure. Without knowing students' pretest measures of attitudes, few conclusions can be drawn regarding the effectiveness of either teaching method in changing attitudes towards AIDS. 5. Summary and implications for occupational therapy curricula This paper analyzed research measuring healthcare workers and students' knowledge about AIDS and attitudes towards persons with AIDS. Results suggest that inaccurate knowledge and negative attitudes still persist within the healthcare profession, including occupational therapy. In addition, research which measures the effectiveness of various AIDS educational programs was examined. Results in this area were more sketchy, with different educational approaches showing some success in affecting knowledge and/or attitudes of participants. Clearly, more research is needed, particularly in the occupational therapy field. Only three studies to date measured occupational therapy practitioners and students' knowledge and attitudes about AIDS, and each has inherent limitations, such as a small sample size, geographic homogeneity, and the use of an untested questionnaire. Additional research on a much larger scale (both

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geographic and sample size) should be undertaken, using an updated instrument which takes into consideration recent advances in AIDS knowledge, and changes in the demographic characteristics of persons with AIDS. Where negative attitudes towards homosexuality have been linked to AIDS these past 10 years, attitudes towards women, Blacks and Hispanics - groups which reported increased incidence of AIDS cases in 1994 (CDC, 1995) - may be linked to AIDS in the coming decade. Instruments which survey attitudes towards persons with AIDS should now include measures of prejudice towards women, Blacks, and Hispanics. Once current information regarding occupational therapy practitioners and students' knowledge and attitudes about AIDS is gathered, AIDS education programs can then be developed and tested in research which measures its effects on increasing knowledge and changing attitudes. Much can be learned from other healthcare disciplines in developing educational programs which effectively target both knowledge and attitudes. While results from the studies discussed in this paper do not identify the most appropriate teaching methods to be utilized in the development of occupational therapy AIDS curricula, some preliminary conclusions can be drawn. Results from both Flaskerud and Johnson suggest the usefulness of didactic educational methods in increasing factual knowledge about AIDS. Furthermore, Vincent and Schkade reported that 92% of occupational therapy students polled expressed a need for more information regarding AIDS, and this information may be effectively conveyed via didactic education. Factual knowledge about AIDS, however, is not enough to ensure that occupational therapy practitioners provide competent and appropriate services to persons with AIDS, as evidenced in all three studies measuring attitudes of OT practitioners and students. The fact that from 11 % (Falk-Kessler et aI., 1994) to 58% (Vincent and Schkade, 1990) of those polled believed they had a right to refuse to treat persons with AIDS indicates a critical need to address attitudinal issues in OT curricula. Various teaching methods have been employed

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to address attitudes with differing results. Johnson (1990) found didactic educational methods to be ineffective in changing medical students' attitudes towards persons with AIDS. Flaskerud (1989) achieved greater success in affecting attitudinal changes in nurses, possibly due in part to the variety of teaching methods utilized in her educational program. Chng and Moore (1991) attempted to affect attitudinal change regarding AIDS through a panel of homosexual speakers who addressed broader issues of homophobia. The results were not significant in changing either measures of homophobia or fear of AIDS, perhaps due to the one-time nature of the panel. Pederson (1993) tested the effects of structured controversy on students' attitudes towards persons with AIDS, with limited significant results. Given the inconclusiveness of these results, a comprehensive experimental study needs to be undertaken in the occupational therapy profession. Such a study would systematically measure the relative effectiveness of the above-mentioned teaching methods in changing OT students' attitudes towards persons with AIDS. Subjects could be drawn from occupational therapy programs across the United States, and the study could include a control group to ensure that attitudinal changes are due to educational efforts, and not to any outside factors. Results of this proposed study will assist in the development of AIDS educational programs for occupational therapy students which address both knowledge about AIDS and attitudes towards persons with AIDS. 6. Conclusion An estimated one million people in the United States will develop AIDS in the next decade, and many of these people will seek the services of occupational therapy. As healthcare professionals, OT practitioners have a duty to provide those services in a competent, equitable, and caring manner. It is the obligation of the occupational therapy profession to ensure that its students are adequately prepared to do so - with accurate knowledge about AIDS and appropriate attitudes towards people with AIDS. The AIDS epidemic will continue to present a challenge to the occu-

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pational therapy profession into the 21st century, a challenge which must be met with sound research, comprehensive education, and ethical practice.

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