Myezwa, Hellen2009-09-012009-09-012009-09-01http://hdl.handle.net/10539/7165PhD thesis, Faculty of Health Sciences, University of the Witwatersrand, 2008This thesis centres around the issues concerning HIV/AIDS and physiotherapy education, curriculum and practice. In particular, this thesis examines which HIV specific content should be included in a physiotherapy curriculum and ultimately presents a conceptual framework for HIV input into the curriculum. There is a vast body of literature available on HIV. For physiotherapists, however, apart from a brief review given by Nixon and Cott (2000) using the ICIDH, no comprehensive literature is available that places information on HIV into a framework that speaks to physiotherapists as part of the rehabilitation fraternity. The literature on impairments is descriptive and buried in the medical model as symptoms. Section one of the literature review placed the literature in such a framework and provided a comprehensive description using the ICF and related aspects that concern physiotherapists. The ICF captures all the elements of current rehabilitation theory and practice and the literature is presented in an ICF framework. In addition, important background information on prevalence, its determinants, treatment approaches and subsequent impacts were reviewed. As most of the literature available still remains in the medical model, the conditions that manifest and from which patients develop impairments, were reviewed. The effects of HIV on body systems are extensive and pervasive. In each body system HIV has direct effects on mature and maturing cells e.g. progenitor cells and mature muscle cells. In the musculoskeletal system HIV impacts on functional systems and organs resulting in pathophysiological changes that manifest as impairments such as muscle wasting. Conditions manifesting in all body systems were reviewed and outlined. Impairments such as pain, breathlessness and proximal muscle weakness were reported in the literature. In addition to impairments, analysis of the literature revealed studies that had found high levels of functional and activity limitations as well as impacts on Health-related Quality of Life in HIV. The literature also presents the current status of physiotherapy interventions. Many studies have reported that exercises are a safe and effective mode of intervention not-withstanding the limitations encountered. The second part of the literature review focussed on aspects concerned with curriculum. Previous studies have focused on establishing baseline knowledge, attitudes and practices (KAP) to HIV and the impact of training programmes on KAP. What the actual content was for health workers, in particular physiotherapists and the approach to incorporating HIV into curricula is a gap in the literature. To inform the overall aim, with context-appropriate HIV content, this study undertook a number of studies in order to obtain the necessary information on HIV, specific to physiotherapy. Therefore the overall approach was a mixed methods one employing both a quantitative and qualitative study mix. The first and second studies informed the clinical picture and were both cross-sectional and descriptive. In both studies descriptive statistics were used to analyse data, especially in determining the absence or presence of conditions. Study 1 sought to establish the level of referral to physiotherapy by retrospectively examining the patient records of patients admitted with HIVrelated conditions over a period of one year. Of the 732 patient records reviewed, 139 (19%) had diagnoses considered suitable for physiotherapy and 3% were referred to physiotherapy. Study 2 aimed to establish a relevant overview of the functional and participation limitations of people living with HIV. Two groups of patients were studied i.e. an in-patient group and an outpatient group. The out-patient group was from a well resourced mining out-patient setting. The ICF checklist was utilised to collect the data and statistical analysis was performed to indicate the presence or absence of impairments, activity limitations and participation restrictions. A logistic regression was done to determine the odds of activity, limitation or participation restriction given certain levels of domains. Both groups showed high levels of impairment. For the in-patient group loss of muscle power 75%(n=60) energy and drive 75%(n=60), disturbed sleep 71%(n=56), emotional problems 62%(49), mild-severe pain 80%(66), weight maintenance difficulties and diarrhoea were apparent. In the out-patient mining group memory problems, energy and drive functions 36%(n=18), sleep 24% (n=12) and emotional functions 28% (n=14), seeing 32% (n=17), hearing, vestibularproblems 28%(n=14) and pain 55%(n=28), blood pressure and respiratory problems 24%(n=12), weight maintenance 63%(n=32), sexual functions 22%(n=11) and reduced proximal muscular power 24%(n=12) were encountered. The in-patient group had high levels of activity limitations and participation restrictions, while the out-patient mining group did not. There was association between the different domains and in the in-patient group gender (p=0.02) and marital status (p=0.01) were likely to influence the activity and participation levels and the experience of the environment. The remaining three studies involved aspects related to informing the curriculum component of this thesis. Study 3 audited the universities’ curricular documents to establish what the current curriculum included. Seven of the eight universities that offer physiotherapy training were reviewed and their curricula were generally scanty on information regarding HIV/AIDS. When compared to the areas outlined as a result of the literature review, the study of the patients and focus groups with clinicians and academic staff, revealed some gaps, in particular; the types of conditionsand the influence of HIV on other body systems which are pertinent to the clinical reasoning process for the physiotherapist: The philosophy of care and approach to management and the physiotherapists’ role in HIV prevention, treatment and care were evident gaps. Study 4 sought to develop a framework of HIV content for a physiotherapy curriculum. This was done by integrating the results found so far and verifying and enriching this data by gaining clinicians’ and academics’ insights and perceptions around HIV, based on their clinical and educational experience. Focus group discussions were conducted and a qualitative approach was undertaken for data analysis. A framework for curricula content emerged from this exercise. In study 5 the framework of HIV content was used to develop a questionnaire that was sent out in the Delphi survey to academic staff with the aim to test the level of consensus. Eighty three components of the curriculum under four outcome areas (Appendix 7.2) were sent to 68 academic staff who were identified. Of the 68 academic staff, 58 were available and 47 responded and consented to participate. All but two topics obtained consensus set at 80% and the remaining two obtained consensus in the second round. The final chapter discusses the results of these studies and illustrates how these results on HIV affect and can be applied to the physiotherapy curriculum, when applied to the UNAIDS mainstreaming criteria. Applying the mainstreaming principles to the process of including HIV content into the curriculum, ensures that the process is not done in a piece meal fashion but encompasses all important facets which were identified. The programme, if systematically implemented, could result in a coordinated outcome accounting for all the important facets. A conceptual framework is drawn from the results of this thesis illustrating the three levels of curriculum taxonomy: At the micro level, through the body systems, the meso level through the role of physiotherapy, dealing with internal and external domains and teaching approaches. The macro level is accounted for by the facilitatory activities such as advocacy among clinicians and academics and forming strategic partnerships at all levels.enHIV/AIDSphysiotherapyThesis