|
Effect of
Training Program on Physicians' Attitude Towards Knowledge and
Practice Related to Assessment and Screening of Clients with
HIV/AIDS
Marietta
Stanton, PhD. RN, Cm [1] and Paige Johnson, RN [2]
[1] Professor and Graduate
Coordinator
Capstone College of Nursing
The University of Alabama
Work: (205) 348-1020
FAX: (205) 348-5559
E-mail: mstanton@nursing.ua.edu
[2] Graduate Assistant
Capstone College of Nursing
The University of Alabama
Recommended
citation format:
Stanton, Marietta, and Johnson, Paige. (2000). Effect of
training program on physicians' attitudes towards knowledge and
practice patterns related to assessment and screening of clients
with HIV/AIDS. Online Journal of Rural Nursing and Health
Care, 1(3) [Online].
Available: http://www.rno.org/journal/issues/Vol-1/issue-3/Stanton.htm
Abstract
This is a study which examines the effects of an educational
program on Hispanic physicians' attitudes towards and knowledge
of HIV/AIDS. The study also examines physicians' practice
patterns related to the screening and testing of Hispanic
patients at risk for the disease. A one on one educational
program was taken to the physician's office at a time convenient
to the physician. A pre- and post-test design is used with
questionnaires developed for the study that assess self-reported
data related to physicians' attitudes, knowledge and practice
patterns. A convenient sample of physicians participated. This
limited the generalizability of the results to other groups.
However, it does point out that a training program can alter
physicians' screening and testing practices as well as their
attitudes towards clients with HIV/AIDS. This has implications
for providers in remote rural areas or in medically underserved
communities where access to formalized continuing education may
be limited or offered at times not compatible with a busy
practice. The study may suggest that one kind of training and
education need to be planned and developed to facilitate
provider participation. Perhaps, on line courses or programs
might be most effective of providing this one on one approach.
Key
Words: HIV/AIDS, Hispanic Physicians, Practice Patterns,
Physician Education
Introduction
The purpose of
this study was to examine the effects of a training program for
Hispanic primary care physicians on their resulting knowledge
of, practice patterns relating to, and attitudes towards the
screening, testing of patients at risk for developing HIV/AIDS
and/or referral of patients who test positive. Several studies
have examined sexual health risk assessment and counseling in
primary care (Manheux, Haley, Rivard & Gervais, 1999: Haley,
Manheux, Rivard, & Gervais, 1999). One study investigated
evaluation of sexual health risk behaviors by primary care
physicians during general medical examinations. A survey, using
a stratified sample of over 1200 physicians, indicated that
fewer than half the respondents reported routinely inquiring
about condom use and number of sexual partners.
Educational
preparation and extended training of physicians has been shown
to have a positive effect on screening, testing and counseling
of patients at risk for developing AIDS. Radecki, Shapiro,
Thrupp, Ghandi, Sangha & Miller's (1999) research demonstrated
that fear and misgivings concerning HIV and perceived need for
screening and testing at risk individuals changed with further
education and training of the physicians. Although significant
changes have been realized in attitudes towards HIV/AIDS,
studies demonstrate that personal prejudices can cause critical
delays in testing and screening (Chesney & Smith, 1999). This
delay in screening and testing by physicians occurs in the
general population. This delay is also prevalent in the
Hispanic/Latino community (Wainberg, 1999).
Residency
training has a profound effect on physicians' screening and
testing behaviors. Medical programs differ in their preparation
of physicians to screen, counsel, refer and/or treat patients
with HIV/AIDS (Yedida & Berry, 1999).
Well over a
million people in the United States are estimated to be infected
with HIV, a national prevalence of 0.3 percent (Freedberg &
Samet, 1999). Studies indicate that general practitioners have
widespread contact with patients testing positively for HIV
(Kirkman, Scott & Bartos, 1999). However, physician's
recognition of common symptoms and sequelae in patients who have
AIDS also needs improvement (Fontaine, Larue & Laussauniere,
1999: Bach, Calhoun & Bennett, 1999). Preventing transmission of
HIV by assessing HIV positive patients for risky sexual and
needle-sharing behaviors is also a critical role for general
practitioners (Gerbert, Brown, Cooke, Caspers, Love & Bronstone,
1999).
A survey by a
leading medical society (1998) indicated that physicians were
not performing routine counseling, screening and testing of
high-risk patients. This study also indicated that physicians
were not always knowledgeable about counseling and the referral
of patients who tested HIV positive.
In conclusion,
it is apparent from the literature that physicians have a great
deal of contact with potential high-risk patients. The
physicians' education and training does not fully prepare them
for screening of or testing related to HIV diagnosis. In
addition, despite the increasing prevalence of HIV, physicians
are not routinely including risk assessment for HIV/AIDS, nor
are they providing counseling to patients testing positive to
halt transmission of the disease. Education and training have
been shown in other disease processes to have a positive effect
on the delivery of care. Therefore, this particular study
evaluated the effect of an educational program on the Hispanic
physicians' knowledge of, attitudes towards, and practice
behaviors with regard to screening, testing and referral of
patients at risk for HIV/AIDS. Since learning is comprised of an
affective domain (attitudes), cognitive domain (knowledge) and a
psychomotor domain (skills/practice), these three areas were
used to evaluate changes in physician behaviors as an outcome of
the training intervention (Mager, 1997).
Background
All Hispanic physicians participating in the training practiced
in predominantly urban, economically disadvantaged, medically
underserved areas (MUA's) where the majority of the physicians'
clients were Hispanic or Latino. The training program was
developed under the auspices of a national Hispanic physician's
medical society. A planning committee of Hispanic physicians
developed the educational program used in the study. Program
content was developed based on the society's survey results from
the approximately 4000 Hispanic physicians who are members.
Based on survey
data, a four-part, modular program on screening, testing of high
risk and referral of patients testing positive for HIV was
developed. The program was implemented on a one-to-one basis at
the physician's place of practice. Six instructors for the
program, all Hispanic physicians themselves, trained for six
months with an attending at a large teaching hospital. This
facility also had an extensive inpatient and outpatient
population of clients diagnosed with AIDS. All of the physician
trainers were bilingual. All materials for the program were
developed by this newly trained cadre of physician instructors
in conjunction with nationally renowned consultants in AIDS/HIV
prevention, detection and treatment. Evaluation materials for
the program were also developed by the physicians and
consultants and will be described in the methodology. Course
materials included an extensive list of testing, referral, and
community support services available to HIV clients. All program
materials were printed in Spanish and English. All four of the
three-hour classes were taught on a one-to-one basis by the
physician instructors in Spanish or English as the physician
learner preferred. Classes followed a lesson plan with very
specific content for each module. Audiovisual materials,
references, handouts and other supplementary course materials
were all standardized for consistency and uniformity. The
modules were scheduled at convenient times for the physician
learner. The rationale for one-to-one instruction was based on
the physicians' expressed needs indicated in the pre-program
survey. This approach allowed the physician instructors to
answer questions, clarify areas of content, and discuss issues
as the learner needed or desired.
Methodology
The basic design for this study was a non-experimental,
pre-test/post-test design to evaluate the effects of the
educational intervention on physicians' attitudes towards,
practice patterns related to, and knowledge about, the
screening, testing and referral process related to HIV detection
and treatment.
Physicians were
recruited to attend the actual program through publications
distributed to the medical society's membership. Physicians
called a point of contact at the organization and indicated
interest in participating. The point of contact at the society
would then contact the interested physician and set up four
appointments for the training to be provided at the physician's
office. Physicians taking the program also referred fellow
professionals from other locations to participate in the
program. All participants for the program were self-selected.
The use of this convenient, self-selected sample population
limits the generalizability of results to any other physician
group. However, this study may provide insight into methods of
providing education to health care providers that may change
knowledge, attitudes, and practice with regard to HIV/AIDS.
Completion of the tests and instruments before and after the
program was voluntary and confidential. Participating physicians
were advised that data would be examined and discussed in the
aggregate and that the instructor would only know their
individual identity.
The physician
trainers in conjunction developed the instruments used to
measure attitudes, practice patterns and knowledge with
consultants. Items requesting demographic data were included
with the instruments administered prior to the course. All three
instruments were administered before and after the course and
were identical.
One instrument
queried physicians' level of knowledge with regard to screening,
testing, referring and treatment of the symptomatic or
asymptomatic patient with HIV/AIDS. The same test was
administered pre- and post-program. This was a standard type of
written objective test with 50 multiple-choice questions.
The second
questionnaire queried physicians' attitudes towards different
aspects of screening, testing and treatment specific to
HIV/AIDS. The instrument used a five point Likert scale with
responses ranging from "not at all" to "all the time". It
contained 30 items. The same test was administered to the
physicians before and after their training was complete.
The practice
pattern questionnaire asked physicians to rate the frequency
with which they performed screening, counseling, testing of high
risk client as well as the frequency of referral and treatment
of symptomatic or asymptomatic clients. It contained 20 items.
This same questionnaire was administered before and after the
educational program.
All three
instruments were administered to physicians in Spanish or
English as the physician learner preferred. Physicians at the
beginning of their first class or module completed pre-program
instruments. Post-program instruments were administered four to
five weeks after the completion of the fourth module or class.
The time frame for the course implementation was July 1998
through February 1999. On average it took physicians about two
months to complete all four modules. The data was collected
during that same time frame.
All instruments
developed were evaluated for face validity by physician
consultants to the project. All instruments were developed for
this study therefore no prior reliability scores were available
on any of the instruments prior to use within this study.
The specific
research question for this investigation was: How will
physicians' test scores differ on knowledge, attitudes, and
practice patterns before and after an HIV/AIDS training program?
Data were analyzed using selected descriptive and nonparametric
measures. Reliability coefficients using Cronbach's Alpha were
determined on the attitude and practice pattern measures. An
item analysis was performed on the objective test measuring
knowledge.
Physicians
completing the program were also asked to complete a learner
evaluation. They were asked to rank order content they found
most helpful within the present course. Participants were asked
to rate their level of satisfaction with instructors, content,
materials and logistics of the completed course. Physicians were
also asked to comment on their self-perceived accomplishment of
the behavioral/educational objectives for the program. The
evaluation instrument used a five point Likert- type scale with
five indicating "high satisfaction" down to one indicating "no
satisfaction."
Results
Approximately
120 physicians completed the training within the July to
February time frame. Of these 120 physicians, there was complete
data for 114 of this group.
The demographic
information collected on the physician participants indicated
that the group was predominantly male (78%) and Hispanic (98%).
The majority of the group had less than 10 years experience
(66%). Approximately 51 percent of the group were in private
practice with the remainder practicing in hospital- or
community-based clinics. Almost all the physician's (95%)
indicated that they had less than 50 clock hours of training on
HIV/AIDS. The major areas of practice for the group were family
or general practice (51%). About 25 percent of the physicians
indicated their practice area was pediatrics; 15 percent
indicated internal medicine; and, five percent indicated
obstetrics and gynecology. The remaining ten percent of the
physicians practiced in surgery or urology or geriatrics.
The average
score on the pre-test assessing knowledge was 80 percent. The
average score on the written post-test was 93 percent with a
range of 80-100 percent. An objective test item with a
reliability of less than 85 percent was not computed into
scoring of the pre- and post-test. Two items were discarded and
the score on the remaining 48 questions were used in computation
of both test scores.
An overall
reliability of r³ .95 was calculated on the attitude instrument
using Cronbach's Coefficient alpha. T-tests performed on the
pre- and post- items of the attitude scale indicated
statistically significant differences on only two of the
attitude scale items selected for measurement in this study.
Results indicated that physicians felt more comfortable
discussing sexual issues with their clients after participating
in the educational program. There were statistically significant
differences pre- and post-program (p< .10) on the discussion of
sexual issues with patients and the physicians' level confidence
in assessing HIV risk behaviors. These changes are portrayed in
TABLE I.
Table I:
T-Tests HIV Training Program Attitudes Towards HIV Infection
|
ITEM |
MEANS
(PRE & POST) |
STD DEV
(PRE & POST) |
SIGNIFIGANCE p³
|
|
|
|
|
|
|
Significance of HIV in Community |
3.75
4.37 |
1.06
1.06 |
.94 |
|
|
|
|
|
|
Discussing Sexual Issues |
2.93
3.20 |
1.30
1.60 |
.02* |
|
|
|
|
|
|
Confidence in Assessing HIV Risk Behaviors |
3.86
4.62 |
.88
.69 |
.001* |
|
|
|
|
|
|
Knowledge of Opportunistic Infections |
3.26
4.19 |
1.03
1.01 |
.82 |
|
|
|
|
|
|
Knowledge of Antireetroviral Therapy |
2.62
3.90 |
1.10
1.05 |
.66 |
|
|
|
|
|
|
Confidence in Treating HIV Clients |
2.4
3.4 |
1.27
1.38 |
.39 |
|
|
|
|
|
|
Motivation to Treat Asymptomatic Patients |
2.79
3.68 |
1.39
1.30 |
.50 |
|
|
|
|
|
|
Motivation to Treat Symptomatic Patients |
2.59
3.41 |
1.48
1.36 |
.38 |
|
|
|
|
|
|
Comfort Treating HIV Infection |
2.10
2.57 |
1.90
2.04 |
.43 |
|
|
|
|
|
|
Comfort Treating Patient with HIV |
1.80
2.28 |
1.74
1.93 |
.25 |
* Statistically Significant
at P³ < 10 Level
An overall
reliability of r³ .95 was calculated on the practice instrument
using Cronbach's Coefficient alpha. T-tests were also performed
on all items in the practice pattern questionnaire. Results
demonstrated statistically significant changes (p<.10) on
specific practice items related to risk assessment and
counseling (See Table II). When examining practice patterns for
physicians treating all age groups in their practice,
statistically significant differences in practice patterns
occurred with patients under the age of 20 (See Table III).
Statistically significant changes occurred with regard to the
actual number of patients tested and/or referred to an
independent lab for testing (See Table IV). Statistically
significant differences were also indicated with regard to
assessment, screening and counseling of patients with high-risk
behaviors (See Table V). All of these differences were
statistically significant at the p<.10.
Table
II: T Tests
Analyzing Changes in Practice HIV Services
|
Item
|
Mean
(Pre & Post) |
STD
(Pre & Post) |
Signifigance P³ |
|
|
|
|
|
|
Risk Assessment |
.77
.97 |
.06
.02 |
.00* |
|
|
|
|
|
|
Pretest Counseling |
.57
.90 |
.07
.04 |
.00* |
|
|
|
|
|
|
Testing |
.62
.81 |
.07
.05 |
.10* |
|
|
|
|
|
|
Post-Test Counseling |
.51
.79 |
.07
.06 |
.16 † |
|
|
|
|
|
|
Treatment Uncomplicated |
.28
.38 |
.45
.49 |
.63 † |
|
|
|
|
|
|
Treatment Opportunistic Infections |
.26
.40 |
.06
.07 |
.48 |
|
|
|
|
|
|
Treatment of AIDS |
.17
.25 |
.38
.43 |
.41 |
* Statistically Significant
at P³. 10 Level of Probability
Table
III: Changes
in Practice
|
Item
|
Means
(Pre & Post) |
STD
(Pre & Post) |
Significance P³
|
|
|
|
|
|
|
Number of Patients Tested |
19
29 |
33
50 |
.006* |
|
|
|
|
|
|
Patients Referred to Lab |
18
42 |
33
46 |
.004* |
|
|
|
|
|
|
Physical Evaluation |
.33
.72 |
.47
.45 |
.71 |
|
|
|
|
|
|
Monitoring of CD4 Counts |
.33
.45 |
.071 .075 |
.71 |
|
|
|
|
|
|
Antiretroviral Therapy |
22
28 |
.45 .42 |
.60 |
|
|
|
|
|
|
Prophy for Opportunistic Infections |
.31
.40 |
.60 .07 |
.69 |
* Statistically Significant
at P³. 10 Level of Probability
Table
IV: T Test
for Practice Changes which Patients Assessed for Risk of HIV
Infection
|
Item
|
Means
(Pre & Post) |
STD
(Pre & Post) |
Significance P³
|
|
|
|
|
|
|
All Patients on First Visit |
.47 .48 |
.07 .07 |
.89 |
|
|
|
|
|
|
All Patients Every Visit |
.66 .68 |
.25 .25 |
.94 |
|
|
|
|
|
|
Selected Patients on First Visit |
.37 .43 |
.07 .08 |
.48 |
|
|
|
|
|
|
Selected Patients on Every Visit |
.22 .20 |
.42 .42 |
.84 |
|
|
|
|
|
|
Patients Between the Ages of: |
|
|
|
|
0-15 |
.00 .09 |
.00 .04 |
.04* |
|
15-20 |
.08 .18 |
.042 .058 |
.04* |
|
20-30 |
.17 .16 |
.057 .055 |
.77 |
|
30-40 |
.13 .13 |
.05 .05 |
.94 |
|
40+ |
.11 .11 |
.04 .04 |
.94 |
|
All |
.022 .045 |
.02 .031 |
.02* |
* Statistically Significant
at P³. 10 Level of Probability
Table V:
Patients with Whom They Discuss Testing
|
Item
|
Means
(Pre & Post) |
STD
(Pre & Post) |
Significance P³
|
|
|
|
|
|
|
Pts with Mulitple Partners |
.90 .97 |
.04 .02 |
.00* |
|
|
|
|
|
|
Men Who Have Sex with Men |
.82 .95 |
.05 .03 |
.00* |
|
|
|
|
|
|
Pts Who Consume ETOH |
.57 .88 |
.07 .04 |
.00* |
|
|
|
|
|
|
IV
Drug Users |
.68 .93 |
.04 .03 |
.05* |
|
|
|
|
|
|
Pts Who Have Had an STD |
.68 .93 |
.04 .03 |
.05* |
|
|
|
|
|
|
Sexually Active Adolescents |
.84 .95 |
.05 .03 |
.00* |
* Statistically Significant
at P³. 10 Level of Probability
Discussion
It is obvious
that the program had an effect on the attitudes towards,
practice patterns for, and knowledge level of the physicians
participating in this educational intervention.
The attitudes
selected for inclusion in the study indicated that the
statistically significant changes for this group of physicians
centered on their discussion of sexual issues and their level of
confidence in assessing HIV risk behaviors. The frequency of
discussion increased as a result of the program. The physicians
self-reported level of confidence also increased as an outcome
of the educational program.
Similarly,
changes in practice patterns reflect a statistically significant
increase in physician's completing risk assessment, pretest
counseling, and testing of patients. This of course, is
self-reported data but the finding is verified by the changes in
the actual numbers of patients tested and/or referred to a lab
for testing by this group of physicians. Although there were no
statistically significant differences in which patients were
assessed for HIV and the frequency of that assessment (first
visit, every visit), there was a statistically significant
changes in the assessment of risk behaviors in patients under 20
years of age. Information provided in the program about the
increasing incidence of HIV/AIDS in the adolescent population
may have prompted physicians to consider risk behaviors in that
group.
There were
statistically significant increases in the frequency of the
physicians' discussions of testing in high-risk groups. This
would indicate that physicians, as they become more aware of the
high-risk groups, would have a tendency to test or refer those
groups with greater frequency.
The physicians
were asked to evaluate the program. The rank ordering of the
most helpful topics indicated that physicians find the
information on assessment, screening and testing most helpful to
their practice (See Table VI). Considering that most of this
group were primary care or general practitioners, the evaluation
seems to indicate that content related to screening and testing
rather than treatment of HIV patients fits the physicians'
learning and practice needs.
Table VI:
Topics Found Most Useful, Rank Order
1.
Counseling
2.
Diagnostics and
Evaluation
3.
ICPS Treatment
Guidelines
4.
Referral
Information
5.
Management of
Asymptomatic Patients
6.
Management of
Opportunistic Infections
7.
Use of
Antiretroviral Therapy
Most physicians
on the final learner evaluation indicated that although they
would refer patients for treatment, knowing the treatment
protocols helped them in the provision of care for unrelated
health problems to symptomatic patients receiving therapy.
Physicians also indicated that content on treatment was helpful
in terms of discussing potential referral and treatment with
clients who tested positive. Evaluation of the course validated
the appropriateness of the one on one teaching. The majority of
physicians indicated that this was most beneficial. The majority
valued the ability to ask questions and clarify content
immediately during the session.
As part of the
evaluation of this program, the physician instructors were also
asked to provide feedback on the process and content of the
program in a focus group session. All of the instructors thought
that the content was thorough and comprehensive. All the
instructors felt that going to physician's office, although
labor intensive, was the only practical way to get the amount of
content to the learners. There was also a discussion of having
the course web-supported with some in person instruction or a
completely web-based format with chat rooms and bulletin boards
to facilitate instructor and learner communication. Others
thought about videotaped instruction or lectures using a CD-ROM
format. Another recommendation from the physician instructors
was to provide the content via videotapes, the internet and/or
teleconferencing(where available) with on site visits to
physician offices for clarification of information and questions
about materials. This might provide a more cost effective but
still convenient approach for the physician learners. However,
what would be the availability of facilities where the
physicians actually practice. These alternatives require further
study. The technology is available to support these other media
options. However, it is unclear how the Hispanic physicians
would respond to or participate in web-based learning or
alternatives.
Conclusions
Educational
programs can alter assessment, screening and testing behaviors
of Hispanic physicians especially those that are tailored to the
individual physician and provided at their place of practice.
Educational interventions can also alter attitudes towards and
knowledge of screening, testing and referral processes. The one
on one learning was well received by the physicians. If this
program could be offered via the web, the course would have
greater availability and accessibility for physicians. It may be
more cost effective than the current method of program delivery.
In medically underserved and rural areas where physicians do not
have access to programs or cannot afford to leave their
practices for extended periods, one on one instruction that goes
to the physician may be required. It is obvious that the
intervention had a positive impact on the knowledge of,
attitudes towards, and practice patterns of physicians relating
to screening, testing and referral with regard to HIV/AIDS.
Using different forms of instructional technology should be
compared to one on one instruction in future studies. This
present study did demonstrate that one on one instruction at the
physician's place of practice enhanced selected aspects related
to screening, testing and referral of patients at risk for
HIV/AIDS in the Hispanic community. Other educational
methodologies should be piloted and tested to ascertain if they
had equally positive results.
Implications
The implications
of this research indicate that an educational program aimed at
specific groups of health providers can modify their knowledge,
attitudes and practice pattern toward HIV/AIDS. It also
indicates that at times education has to be brought to the
provider on their terms rather than in formal programs at a
distance from their practice.
All of the
providers in this study practiced in Hispanic or Latino
communities in predominantly large urban, medically underserved
areas along the eastern and southeastern United States. However,
there was a small cadre of physicians who dealt with migrant or
seasonal farm workers in the southeast. All of them were
unfamiliar with the community resources to support screening and
testing processes.
It was very
apparent in this study that physicians do not necessarily
receive all the necessary knowledge regarding HIV/AIDS. They
required additional training and education to adequately assess
and screen at risk clients. This may indicate that more
information and training is required during basic preparation to
integrate this knowledge into the curriculum. It may also
indicate that other providers also do not receive in depth
training on HIV/AIDS.
Just as this is
critical in the Hispanic community in the inner city, it is
equally important to those physicians and other primary
providers in rural communities. Their knowledge, attitudes and
practice patterns related to HIV/AIDS will impact on their
assessing risk, screening and/or referral for testing. As
HIV/AIDS becomes more prevalent in rural communities, it is
important that the health care providers who are the front line
for prevention are more knowledgeable about risk factors and
adequate screening and referral. If rural providers can't access
important information about HIV/AIDS, then appropriate methods
for bringing it to them must be a priority.
Limitations
This is a
self-selected, relatively small group of physicians. Responses
of this group are certainly not generalizable to other groups of
physicians. This intervention was used and evaluated primarily
with Hispanic physicians practicing in largely Hispanic
medically underserved communities. Physicians practicing in
these areas are limited in number and have typically large
practices. The size of their practice has a direct bearing on
the physician's ability to access other forms of education.
Therefore, comparisons between this educational approach and
others potential programming were not possible for this group of
physicians.
Recommendations
It is
recommended that other forms of programming be developed and
evaluated to ascertain if they achieve similar results with
larger more representative physician samples. It is also
recommended that this study be replicated with a larger cadre of
rural physicians who treat migrant or seasonal workers. The
approach used to reach the physicians in this study could be
modified and used for other health care providers working in
rural or other medically underserved areas. Other professional
health care provider like their physician colleagues may not
receive adequate preparation in terms of HIV/AIDS screening,
testing and referral. HIV/AIDS is certainly not just a urban
problem, the incidence and prevalence of it in all age groups is
increasing rapidly in rural areas (Bushy, 2000). As the
incidence increases, serious plans for the education of rural
providers will need to be developed. The approach in this study
worked for these physicians perhaps the approach would be
appropriate for rural physicians and health care providers as
well.
1.
Bach, P. B.,
Calhoun, E. A., & Bennett, C. L.(1999).The
relation between physician experience and patterns of care for
patients with AIDS-related Pneumocystis carinii pneumonia -
Results from a survey of 1,500 physicians in the United
States.Chest, 115(6), 1563-1569.
2.
Bushy, A. (2000).
Orientation to Nursing in the Rural Community. Thousand Oaks,
California: Sage Publications, Inc.
3.
Chesney, M. A., &
Smith, A. W.(1999).Critical
delays in HIV testing and care - The potential role of
stigma.American Behavioral Scientist, 42(7), 1162-1174.
4.
Fontaine, A.,
Larue, F., & Lasssauniere, J. M.(1999).Physicians'
recognition of the symptoms experienced by HIV patients:How
reliable?Journal of Pain & Symptom Management, 18(4), 263-270.
5.
Freedberg, K. A.,
& Samet, J. H.(1999).Think
HIV - Why physicians should lower their threshold for HIV
testing [Review].Archives of Internal Medicine, 159(17),
1994-2000.
6.
Gerbert, B.,
Brown, B., Volberding, P., Cooke, M., Caspers,
N., Love, C., & Bronstone, A.(1999).Physicians' transmission
prevention assessment and counseling practices with their HIV
positive patients.AIDS Education & Prevention, 11(4), 307-320.
7.
Haley, N., Maheux
B., Rivard, M., & Gervais, A.(1999).Sexual
health risk assessment and counseling in primary care: How
involved are general practitioners and obstetrician-gynecologists?American
Journal of Public Health, 89(6), 899-902.
8.
Herek, G. M., &
Capitanio, J. P.(1999).AIDS
stigma and sexual prejudice.American Behavioral Scientists,
42(7), 1130-1147.
9.
Kirkman, M.,
Scott, M., & Bartos, M.(1999).GP's
involvement in the management of patients with HIV/AIDS in
Australia.Venereology-TheInterdisciplinary International Journal
of Sexual Health, 12(3), 105-110.
10.
Maheux, B.,
Haley, N., Rivard, M., & Gervais, A.(1999).Do
physicians assess lifestyle health risks during general medical
examinations?A survey of general practitioners and
obstetrician-gynecologists in Quebec.CMAJ, 160(13), 1830-1834.
11.
Mager, RF (1997).
Preparing instructional objectives:A critical tool in the
development of effective instruction. Atlanta, GA: The Center
for Effective Performance, Inc.
12.
Radecki, S.,
Shapiro, J., Thrupp, L. D., Gandhi,
S. M., Sangha, S. S., & Miller, R. B.(1999).Willingness to treat
HIV-positive patients at different stages of medical education
and experience.AIDS Patient Care & Stds., 13(7), 403-414
13.
Wainberg, M.
L.(1999).The
Hispanic, gay, lesbian, bisexual and HIV-infected experience in
health care.Mount Sinai Journal of Medicine, 66(4), 263-266.
14.
Yedidia, M. J.,&
Berry, C. A.(1999).The
impact of residency training on physicians' AIDS-related
treatment practices: A longitudinal panel study.Academic
Medicine, 74(5), 532-538.
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