Three themes describing physiotherapists’ poor awareness of falls risk and bone demineralisation in PLWH and suboptimal fall prevention services were identified (Table 3). Themes, categories and verbatim supporting quotations are presented below.
Table 3
Themes and categories identified from interview data
Theme
|
Category
|
Physiotherapists (un)awareness of falls risk
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Not anticipatory of falls in PLWH
|
Falls associated with geriatric population
|
Unaware of serostatus of PLWH
|
Minority of physiotherapists aware of falls in PLWH
|
Physiotherapists (un)awareness of bone demineralisation in PLWH
|
Unaware of effects of HIV or ART on bones
|
Inaccessible facilities for BMD measurement
|
Minority of physiotherapists aware of bone demineralisation in PLWH
|
Suboptimal fall prevention services
|
Fall risk assessment not prioritised
|
Inadequate primary fall prevention strategies
|
No screening or assessment tools available
|
Inadequate referral to multidisciplinary team by physiotherapists
|
Theme One: Physiotherapists’ (un)awareness of fall risk in PLWH
Most physiotherapists expressed that they were not aware of the potentially inherent fall risk that could be present in PLWH. The physiotherapists acknowledged that they had not been anticipatory of falls in PLWH and had never thought of assessing falls in this population.
‘It’s difficult for me to explain that question directly…but specifically to say that this person is HIV positive hence they have this risk of falls, I haven't really observed that.’ Participant 14, Zambia.
Some still expressed some level of uncertainty towards this phenomenon being evident in PLWH. Conversely, some who had been initially unaware of falls in PLWH were able to, in retrospect, conclude that falls were a problem in PLWH.
Most participants perceived falls as a geriatric condition that is not particularly characteristic in PLWH.
‘…because mostly when we are talking about falls, we are talking about it in the elderly…but never have you ever heard an emphasis being put on falls with people living with HIV.’ Participant 21, Zimbabwe.
A few physiotherapists shared that patients were sometimes unaware of their HIV status because of not routinely testing for HIV. Sometimes patients who were aware of their seropositive status did not reveal it to their physiotherapists, especially when the therapist did not inquire about it. Therefore, the physiotherapists could not always associate presenting comorbidities and impairments with HIV or ART during assessment.
However, less than a third of the physiotherapists, mostly from Botswana and South Africa, recognised the problem of falls in PLWH. Falls were observed both in community-dwelling and hospitalised PLWH, with variable fall rates estimated between 5% - 60%. A few physiotherapists were aware of the risk factors for falls in PLWH, mostly attributing it to balance impairments (due to impaired sensation and loss of proprioception), frailty, muscle wasting, dizziness, ART non-adherence and comorbidities such as depression, tuberculosis, cerebral meningitis, stroke, hypertension, Kaposi Sarcoma and peripheral neuropathy. Two physiotherapists were aware of the negative impact of falls on the lives of PLWH, mentioning consequences such as fear of falling and fall-related fragility fractures.
Theme Two: Physiotherapists’ (un)awareness of bone demineralisation in PLWH
Most physiotherapists were not aware of the effect of HIV infection or ARVs on increased risk of bone demineralisation in PLWH. They were aware of other side effects of ART such as lethargy, paraesthesia and myalgia but not accelerated bone loss.
‘Some of my patients have presented with just general complaints after starting ARV’s maybe, they are feeling tired, they are feeling weak and also like general joint pain or body pains as well…I can’t say that it has been on their bones no.’ Participant 8, South Africa.
‘I don’t have enough understanding on that aspect. I only know that ART can have an effect on the nerves… On the nerves, yes, I know, but on the bones, I am not so much sure.’ Participant 11, Zambia.
Some felt that it would require a bit of research to compare the differences in BMD of PLWH and seronegative patients. All the facilities did not have dual energy x-ray absorptiometry (DXA), considered the gold standard for BMD measurement. Most used normal x-rays as their main diagnostic tool for osteoporosis with limited use of computer topography due to its high cost.
A minority of the participants (n=3) supported the fact that ART or HIV infection itself can have a negative impact on BMD, having observed osteoporotic bones on X-rays of PLWH. A few cases of pathological fractures in PLWH were also reported. Some participants attributed bone loss in PLWH to effects of prolonged bed rest rather than effects of ART or HIV infection itself.
Theme Three: Suboptimal falls prevention services
All the physiotherapists perceived their current fall prevention practice as suboptimal. This theme described factors mentioned by the physiotherapists that supported this notion.
Fall risk assessment not prioritised in PLWH
Because they were not aware that PLWH had a high risk of falls, most participants did not routinely assess for falls risk in this population. They prioritised other conditions that PLWH presented with for physiotherapy management. Very few physiotherapists subjectively asked about falls history in PLWH. The physiotherapists were not carrying out multifactorial risk assessments, especially in patients who had not presented with complaints of falls, even though they were able to identify patients with balance impairments during traditional assessments.
‘I haven’t been doing that much, you know assessing the risk of fall, really unless if it's in the elderly patients, perhaps at the end of neuro rehabilitation just as a screen to see if this patient needs more rehabilitation or not, but in general we don’t really assess so much of the risk factors.’ Participant 2, Botswana.
One physiotherapist expressed concern regarding the high workload that would result if she did her own routine assessment and preferred to only assess fall risk in patients who had been referred by the doctors. It was also reported that doctors rarely referred PLWH specifically for falls prevention.
Inadequate primary falls prevention strategies
Most participants reported that they did not have any primary prevention strategies but focused more on secondary prevention for patients who have already experienced falls.
‘I don’t think we have anything in place for falls prevention. I think we only start treatment when we find that someone has been falling a lot.’ Participant 4, Botswana.
Common secondary prevention strategies employed in their current management of falls among PLWH included balance retraining, muscle strengthening, recommending and training use of assistive devices (Figure 1).
No screening/assessment tools available