A COMMUNITY APPROACH TO PHYSIOTHERAPY P } Wallner, BSc Physiotherapy Lecturer, Department o f Physiotherapy, University o f the Witwatersrand A Stewart, BSc Physiotherapy, DPE, MSc Medicine Senior Lecturer, Department o f Physiotherapy, University o f the Witwatersrand Reasons for the introduction of a com­ munity com ponent to the current physiotherapy curriculum: A quick and selective survey o f the South African community reveals: • The population of South Africa in 1992 was 39,4 million1. • Africans make up 76% of the popula­ tion2. • The Urban foundation estimates that by the year 2010 the total population will have increased by 55% and that be­ tween 1991 and 2010 a total of 14 million Africans will be added to the urban and metropolitan population . • Fifty percent of people in rural areas have an inadequate water supply and 75% have inadequate sanitation2. • High levels o f violence prevail. Re­ searchers at the Centre for the Study of Health Policy cite a figure of approxi­ mately 15 000 murders annually or 42 per day, this being six times higher than the USA3. In 1991, the Director General of the De­ partment of National Health and Popula­ tion D evelopm ent, C oen Slabber esti­ mated that the private sector catered for approxim ately 20% o f the p opulation through their membership of medical aid schemes. The remaining 80% relied on the public sector for their health care deliv­ ery4. Research undertaken by Smith in 1991 revealed that only 20% of the physiothera­ pists registered with the South African M edical and Dental Council w ere em­ ployed in the public sector5. The Minister of Health and Population Development announced in May 1991 that the philosophy of primary health care, which has been adopted in most develop­ ing countries decades ago, would be im­ plemented in South Africa. The Department of Physiotherapy re­ cently examined their curriculum in order to ascertain whether it was training gradu­ ates to meet the needs of the entire popu­ lation. In the past, the training at the Univer­ sity placed a major emphasis on the devel­ opment of a first world therapist. The pri­ vate and export sector have been well ca­ tered for as can be seen by figures collected in 1992. An unpublished survey of gradu­ ates over the last 10 years revealed that 20% of our graduates have left the country. A further 10% have left the profession. Of the remaining 70% of the sample group, 74% are currently working in private prac­ tice6. These figures show that our gradu­ ates are not providing a service to the ma­ jority of the population at all. It would not be unreasonable to extrapolate this to most other training facilities in the country. It was therefore felt that, because there was a changing emphasis in health care and our graduates are clearly not meeting the broad health needs of the country, changes needed to be made to the physio­ therapy curriculum. Our graduates need to be trained to function effectively in the essentially transitional and developing South African situation. It was necessary to begin to expose our students to the real­ ity of the communities from which their patients come such as: • a depressed socio-economic environ­ ment • insufficient transportation services • violence as a daily experience • discrimination on a very broad scale • poor education. In addition our students were not able to communicate in a common language which led to a breakdown in therapeutic communication. The mission statement of the depart­ ment of Physiotherapy reads as follows: "The department strives towards de­ veloping the highest standards of aca­ demic and clinical excellence. We aim to produce responsible, innovative, critically thinking professionals committed to meet­ ing the health needs of all the communities in South Africa, appropriately and cost ef­ fectively." In order to achieve this goal, it was de­ cided to include a community component into the four-year training. It is important to emphasise that this was taken with the express proviso that the standard of our training would not drop. On the contrary, this component, together with new teach­ ing techniques, would allow for learning based on greater insight. Our aim was to expose all our students to alternative facili­ ties of health care delivery as the only ex­ perience they had was in urban institu­ tions such as the Johannesburg General and Baragwanath Hospitals, both tertiary training hospitals. Another important ob- 'ABSTRACT ^ This paper explores the reasons for the introduction of a community component to the current physio­ therapy curriculum. The develop­ ment of the community compo­ nent of the course is outlined as are the student attitudes towards this development. The necessity for this trend to continue in the interests of meeting the rehabilitative needs of all the communities in South Africa ^ is highlighted._________________^ jective was to offer students who had very little experience of life outside the pro­ tected en v iron m en t o f p red om inantly white affluent areas, an exposure to the conditions in which the majority of their fellow citizens live. D evelopm ent of the com m unity compo­ nent of the curriculum and student atti­ tudes related to th is developm ent In 1991, the community component of the course consisted of a two week period at one of three rural hospitals in the "self- governing state" of Gazankulu during the fourth year of study. Here the students were exposed to the problems which peo­ ple face in rural areas and to examples of primary health care delivery systems. The students received very little preparation for the rural visit. The community syllabus was not sufficiently specific in its objec­ tives to give the students an overall under­ standing of the South African context. In 1992, the block w as expanded to three weeks in response to a student evalu­ ation expressing the wish to spend more time in the area (Fig 1). The evaluation consisted of a questionnaire in which the students w ere asked to rank their re­ sponses to questions on a scale of 1-5. Too long Just right Too short Fig 1: Student perception of lime spent on rural block In order to prepare the class more ade­ quately for their rural block in fourth year, concepts such as Primary Health Care and Community Based Rehabilitation were in­ troduced in 1992. The course evaluation revealed that the students did in fact feel more prepared for the block (Fig 2). Biadsy 54 Fisioterapie, Augustus 1994 Dee! 50 no 3 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) □ 1991 n-33 ~ 10 v> 5 • 1 2 3 4 5 Strongly disagree Strongly agree _ _ _ _ _ _ Fig 2: Felt well prepored for rural block_ _ _ _ _ _ During the three week stay, the stu­ dents were expected to offer a service to the hospital for 50% of the time. The re­ maining 50% was spent on the various outreach services and facilities. We felt that because students learn the most in a "h a n d s o n " s itu a t io n and as the Gazankulu governm ent funds the stu­ dents stay, the service component to the hospital and surrounding community was vital. As this was, unfortunately, the only clinical placement in which they worked together with physiotherapy assistants, the students perception of how they were able to work with auxiliary staff was sur­ veyed. This shows that the students felt they w orked b ette r w ith the ph ysio­ therapy assistants in 1992 than in 1991 (Fig 3). This we attributed to a directed commu­ nication course which was introduced as well as the preparation and orientation that they received before they arrived at the rural hospital. 20 -I Q 1991 n=33 I 1 5a . £ ~ 10 c••o3 w 5 1992 n-33 H Strongly disagree Strongly agree Fig 3: W as able to w ork well with physiotherapy assislants Student responses have generally been very positive to this rural block experience. The sentiments expressed included: • It was a very useful eye opener and a unique experience. • I didn't know these facilities existed. • I learned about coping with limited space and equipment. • The best experience was the sleep over in the community. This gave me insight into the way people live. It was a very informative and w orthw hile experi­ ence. • I now appreciate all the things I take for granted. • It is essential that all physiotherapy stu­ dents get this kind of exposure. • I n o tice d how m an y p e o p le need physiotherapy but are not getting it be­ cause they live too far away from the hospital or clinic. • I was frustrated at working at a very slow pace. In 1992 more students expressed an in­ terest in returning to work in a rural area 1991 1992 n -3 0 n-33 Fig 4: Would consider working in a rural area than did the students in 1991 (Fig 4). Until 1992, the community content em­ phasised rural environments. W ith the abolition of the pass laws, rapid urbanisa­ tion is occurring, with estimated numbers of informal settlers varying from 3,5-7 mil­ lion in metropolitan areas . An urban com­ ponent was added to the course in 1993 in order to help dispel the misconception that community is synonymous w ith rural populations. In the urban community week, the students have a chance to ex­ plore disability issues and the concept of resource gathering and networking in an urban environment. During this week they participate in visits to facilities which offer services and opportunities to disabled people. In the third year of study, all students spend four weeks in a community block. One week is spent at the Soweto clinics offering physiotherapy services. (This was introduced after surveying the numbers of patients who attend these clinics. Fig 5 represents attendances from January to September 1992). The high attendances of people with neurological problems, mainly head injury and cerebral vascular accidents, prompted us to encourage the students to run classes for these patients and also to treat the other patients who attend these clinics. Three days are spent at ante and post natal facili­ ties, one of which is in a high socio-eco­ nomic suburb of Johannesburg. Six days are spent in chronic disease clinics at the Johannesburg General hospital. The last six days are spent giving exercise classes to the active and frail elderly in various com­ munities around Johannesburg. Throughout the four , year training the students receive lectures on: • Primary health care • Community based rehabilitation • Social welfare and benefits available in South Africa. • Cultural beliefs and differences related to health care. • Adult education • Epidemiology • Community analysis Also included are: • Workshops on communication • A simulated disability exercise. • A visit to the home of a disabled person. • A twenty five hour course in an African language. This particular course was introduced as the majority of our students are from white, English-speaking, privileged back­ grounds and few are able to speak a black language. As 76% of the population is Af­ rican2, we feel it is essential that the stu­ dents acquire these communication skills. Problem s encountered T h e in tro d u c tio n o f a com m u n ity physiotherapy component to our curricu­ lum is not without problems. The rural hospitals, which we are able to utilise, are a six hour drive away and consequently the university input to these facilities is minimal, namely four brief vis­ its annually. We rely as we do in all clinical placements on the existing clinical staff. Our urban community component at the Soweto clinics is running reasonably well but not all the university teaching staff'are sufficiently exposed to this ap­ proach to physiotherapy to ensure ade­ quate carry over into the teaching environ­ ment, although all areas of clinical study now have community orientated objec­ tives. There is some resistance from students who feel that this component is not impor­ tant even though it is an examinable course with the same weighting as other major subjects. This may be due to their percep­ tion that community work is not special­ ised enough. The fact that the communities in which they work in are foreign and alien a> 1 2 0 0 -| oc<9*o 1 0 0 0 - ca> 8 0 0 - <9 6 0 0 - 4>_o 4 0 0 - E3 z 2 0 0 - 0 - Hwiriptogle O A 7 A A O th # r O r t h o - B a c k / R M p I r - P a ra p ta g l* B u rn * A m p u t » a i p l t d l c u a d i pain a to ry Fig 5: Attendances at Soweto Clinics continued ove rleaf.. Physiotherapy, August 1994 Vol 50 No 3 Page 55 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) & \ o 6 s d i * t > r > - i * *\pU j- c * f t * y e / ' * ' S o ^ “ If you’d like to work in the US, contact HPI. We've helped more physical therapists find great jobs in America than any other recruiter. Top pay, expert licensing and visa processing. Fees paid by your employer. IIIIIH Pl The Leader in International Healthcare Recruiting 812 Oak Street, Winnetka, IL 60093 USA (Reverse Charges) 708-441-8384 Fax: 708-441-8401 .. .continued from previous page to them may play som e part in this resistance. Perhaps w h en w e eventually start to train stud ents from a w id er cross-section o f our com m unity this resistance w ill be less evident. Conclusion In the three years since the d evelopm ent o f a structured com ­ m unity course, the university has started to address som e o f the pressing issues w hich face ou r profession. It is evident from the A N C policy d ocu m ent on health, a m ajor decision m aker in the future, that all courses offered for health professionals need to be transform ed, upgraded or m odified so that they are appropriate to m eet the needs o f the entire p o p u latio n 7 and not only the financially privileged as is the case at present. T he ethical issue o f the neglect of the rehabilitative needs o f the m ajority o f the population has eluded our profession up to now. This restru cturing o f the physiotherapy course at the University o f the W itw atersrand m ay have the effect of our future graduates being able to play a m ore ap propriate p art in providing a service for the m ajority of the population. REFERENCES 1. South African Institute of Race Relations. Race Relations Survey 1992/3 1993, Published by Gavin and Sales. 2. South African Institute of Race Relations. Race Relations Survey 1991/2 1992, Published by Gavin and Sales. 3. Eagle G. Violence in South Africa: on the increase in the 1990's. Critical Health 1992;41:7. 4. Editorial Board. The Winds of Change? An Interview with Dr Coen Slabber. Critical Health 1991;35:14. 5. Personal Communications, Elsa Smith, Control Physiotherapist, Trans­ vaal Provincial Administration. 6. Blecher L, Bridgeford, Kirk J et al. 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