008 Layout 32 SA JOURNAL OF PHYSIOTHERAPY 2009 VOL 65 NO 3 INTRODUCTION The use of information and communi - cation technology (ICT) in all spheres of human endeavour has become increas- ingly evident over the past decade, with people of all ages making use of computers and the Internet to interact, communicate and do business on a daily basis (Louw & Hanmer, 2002). In South Africa, the increasing availability of broadband Internet access has resulted in the rise of social networking, online consumer forums and multimedia on demand services that are changing the way we communicate and engage with each other. However, while the use of ICT in many aspects of society has increased, not everyone has equal access to technology, partly as a result of the policies of apartheid prior to 1994 (Bozalek et al, 2007). This has led to a phenomenon known as the “digital divide”, or the gap between those with access to technology and those without (Samuel et al, 2004). Despite this, the use of ICT to facili- tate learning has found support among many scholars (Oblinger & Oblinger, 2005; Rohleder et al, 2007). The South African government has also indicated that ICT has the potential to improve the quality of education and training and has pledged to “...invest in national initiatives to increase access...and pro- vide electronic resources of the highest quality...” to students in South Africa (Department of Education, 2004, p. 11). This investment in technology is essen- tial, as today’s students in higher edu - cation are part of the first generation to have access to the vast resources of the Internet and who use it regularly. There is also evidence that they are not only comfortable with technology, but that it has fundamentally changed the way they communicate and learn (Barnes et al, 2007). This change has led to educators in higher education questioning how their institutions are adapting to take advantage of these new tools and the new methods of teaching that they enable (Oblinger & Oblinger, 2005). Social constructivism is one theore - tical approach that advocates the use of ICT in education, as it facilitates active student engagement with content, edu- cators and each other, enhances problem- based learning, improves information gathering skills, improves communica- tion between educators and students, ensures the accessibility of course- work and enhances administrative tasks (Johns, 2003; Oblinger & Oblinger, 2005; The use of information and communication technology by South African physiotherapy students R e s e a r c h A r t i c l e A BST R A CT: The global shift toward the use of information and commu - nication technology (ICT) in health education and practice has been shown to enhance both the educational opportunities and the support provided to students and healthcare professionals. This study aimed to investigate the use of ICT by South A frican physiotherapy students and what their experiences and perceptions were regarding their use of ICT as part of their studies. The study design was a cross-sectional, descriptive survey using a self-administered questionnaire. The survey population included all of the undergraduate physiotherapy students from six of the eight universities offering the physiotherapy degree in South A frica (N=1105). The sample size consisted of 529 students from the survey population who completed and returned questionnaires, indicating a response rate of 48%. The results of the study showed that the use of ICT by South A frican physiotherapy students varied according to task, racial group and university attended. Furthermore, the reported use of ICT for communication, research and continuing professional development was low. In conclusion, this study indicates that with a move toward the use of ICT to enhance health education and practice in South A frica, certain groups of physiotherapy students may be at a disadvantage if required to make use of ICT as a means of improving communication, enhancing education, participating in lifelong learning opportunities and accessing support. KEY W ORDS: INFORMATION A ND COMMUNICATION TECHNOLOGY, PHY SIOTHERA PY, STUDENTS, SOUTH A FRICA , EDUCATION. M Rowe (MSc), P Struthers (PhD) Correspondence to: M Rowe Department of Physiotherapy University of the Western Cape Private Bag X17 Bellville 7530 South Africa Email: mrowe@uwc.ac.za SA JOURNAL OF PHYSIOTHERAPY 2009 VOL 65 NO 3 33 Rohleder et al, 2007). The use of ICT in education has also been shown to increase the channels of communication and facilitate collaborative learning (Boulos et al, 2006), creating a frame- work for the social construction of knowledge. These characteristics of the use of ICT in education allow students to take greater responsibility for learn- ing, and for educators to act as facili - tators of learning. The use of ICT in clinical practice has been shown to facilitate evidence based practice (EBP); improve the opportuni- ties for continuing professional develop- ment (CPD); and enhance communica- tion between colleagues (Rowe, 2008). However, while many physiotherapists support the concept of EBP in principle, many found it hard to implement due to a lack of access to literature and isolation from their peers (Grimmer- Sommers et al, 2007). These issues with EBP have been identified as ones which could potentially be addressed through the use of ICT (Hill & Alexander, 1996; Mitchell et al, 2001; Taylor & Lee, 2005). Therefore, if ICT is going to be the means by which clinicians gain access to the latest evidence as part of their practice, it indicates a need for healthcare students to be literate in it’s use. In fact, computer literacy has been recognised as an essential skill for future healthcare professionals to function effectively in an increasingly digital workplace (Samuel et al, 2004; Kingsley & Kingsley, 2009). In terms of the actual acquisition of these skills, doctors in the United Kingdom (UK) have reported that self- directed learning was the means by which they learned how to use a com- puter (National Health Service, 1998). With a lack of access to ICT resources in South Africa (Bozalek, 2007), self- directed learning as a means of acquir- ing these skills may not be a feasible solution. Other studies have identified more problems with the use of ICT in medical education, including the fact that there is often poor engagement with content when materials are poorly designed, both staff and students need adequate training in order to make use of computer assisted learning tools, and there is often resistance to change (Greenhalgh, 2004; Kingsley & Kingsley, 2009). Together with the high cost of developing digital resources and the poor time management that is often associated with e-learning and distance learning (Martin, 2007), it is evident that the implementation of ICT in healthcare education should be undertaken with caution and careful deliberation. Aim of the study While there is a significant worldwide shift towards the use of ICT to enhance healthcare education and clinical prac- tice, its use among South African physio therapy students has not been well documented. Thus, the aim of the study was to determine which ICT resources South African physiotherapy students use during their undergraduate education, and what their experiences and perceptions were regarding that use. METHODOLOGY A cross-sectional, descriptive survey was used to determine the use of ICT among physiotherapy students at six of the eight training institutions in South Africa, in 2007. The population for the study included all registered under- graduate physiotherapy students in the country. However, for logistical reasons the Universities of the Free State and Pretoria were unable to participate, with the Universities of Cape Town, Kwazulu-Natal, Limpopo, Stellenbosch, Western Cape and Witwatersrand yield- ing a sample of 1105 students. No exclu- sions were made. As no validated, reliable instrument could be found, a self-developed ques- tionnaire was used, which was based on questionnaires used in similar studies identified in the literature, as well as the authors personal experiences. The ques- tionnaire was divided into three sections that were based on the areas in which information was sought and that would satisfy the objectives of the study. The sections included: demographic infor- mation; use of ICT at university and at home; students’ experiences and percep- tions of support; and use of ICT. A com- bination of Likert scales, “Yes/No” answers and one open-ended question were used to gather information. A pilot study was conducted with a small group of newly qualified physiotherapists, in order to improve the content validity of the questionnaire. Irrelevant or ambi - guous questions were either modified or removed so that reliability could be improved. The response rate was maxi - mised by using stamped, self-addressed envelopes; including cover letters; send- ing reminders to participants; and offer- ing book vouchers to three randomly selected participants. Questionnaires were hand-delivered to the three physio- therapy departments in the Western Cape Province, and posted to the depart- ments in other provinces. Questionnaires and cover letters explaining the study were sent to class co-ordinators in each physiotherapy department, which they distributed to their respective classes. Students were asked to complete the questionnaires and return them to the researcher by post. Data were captured and coded using the OpenOffice spreadsheet appli- cation and descriptive and inferential statistical analysis was performed using the Statistical Package for Social Science (SPSS), version 16. Statistical significance was set at p equal to or less than 0.05. Ethical clearance to conduct the study was obtained from the University of the Western Cape, and permission obtained from the heads of each physiotherapy department who agreed to participate. Consent was implied by completing and returning the questionnaire and anonymity was ensured by not collect- ing personally identifiable data. Class co-ordinators were asked to inform stu- dents that participation was voluntary and that their anonymity would be ensured by not gathering any personally identifiable information. There were no risks in participating in the study. RESULTS The demographic data of the partici- pants are presented in Table 1, with 529 respondents representing a response rate of 48%.1 Eighty two percent of respon- 1 Percentages in the text have been rounded off to the nearest whole number. 34 SA JOURNAL OF PHYSIOTHERAPY 2009 VOL 65 NO 3 dents were female, 41% were White and more than half (51%) were between 16 and 20 years old. Most participants (92%) reported using ICT at university, with 74% using it at least weekly. There was a signifi- cant relationship between race and the frequency of ICT use at university (p=0.000), with Black students being the most frequent users (91% using it at least weekly), then Coloured and Indian students (79% and 77% respectively) and White students using ICT the least (61% at least weekly). It was also found that the university attended was a signi - ficant factor in the frequency of ICT use (p=0.000), as shown in Figure 1. Few Black students reported having access to the Internet when they were in high school (18%) and at home (15%), prior to attending university, which is in stark contrast to the 60% of White students who had Internet access at high school, and 78% who had access at home. Table 2 indicates that using online search engines was the most common use of the Internet at university (85%), and accessing the departmental website the least common use. The use of online databases (53%) and journals (48%) was found to be low. The use of email while at university was also reported to be low (48%), with only 26% of these respon- dents reporting using it to communicate with their peers and lecturers (not shown Variable n % Gender Female 432 81.7 Male 97 18.3 Age 16-20 270 51 20-25 244 46.1 26-30 11 2.1 31-35 2 0.4 35-40 2 0.4 Race* Black 117 22.1 Coloured 126 23.8 Indian 64 12.1 White 219 41.4 * The use of racial categories recognises the socio-economic impact of the policy of apartheid prior to 1994. The categories used in this study were based on the government’s racial classification system during that time. In the past, population group was based on a legal definition, but it is now based on self-perception and self-classification. Coloured in this context is a popu- lation of mixed ancestry. Table 1: Demographic data of respondents (N=529) Online activities n % Online search engines 447 84.5 Online library 332 62.8 Physiotherapy-related websites 322 60.9 Online databases 280 52.9 Online journals 255 48.2 Course-related email 252 47.6 Department websites 217 41 Table 2: Physiotherapy students’ use of the Internet at university (N=529) 80 70 60 50 40 30 20 10 0 US UCT UL UKZN UWC UW Daily Weekly Monthly Rarely Figure 1: Frequency of ICT use at university (N=529) US – University of Stellenbosch UKZN – University of Kwazulu-Natal UCT – University of Cape Town UWC – University of the Western Cape UL – University of Limpopo UW – University of the Witwatersrand SA JOURNAL OF PHYSIOTHERAPY 2009 VOL 65 NO 3 35 in Table 2). There was a significant rela- tionship between the activities per- formed online (see Table 2) and the uni- versity attended (p=0.000). The most common reason given for using the Internet at university was to prepare assignments (83%), which was followed by academic development (43%). The least common reason was to seek clinical advice or guidance (23%). Forty eight percent of students used the Internet at university for personal interest. Table 3 shows that most physiothe - rapy students (>70%) reported that they were confident in performing searches on the Internet, sending email, printing documents, writing letters or records, preparing presentations and for profes- sional development. Research, gaming, forum discussion and exercise prescrip- tion are the activities that physiotherapy students reported being uncertain or not confident in performing. Additionally (not shown in table), most respondents indicated a preference for face-to-face contact (95%), rather than email (25%), as the means by which they access support. Students also reported that they believed that ICT would be beneficial in their clinical practice, including making administrative tasks and communication easier (95% and 87% respectively), improving the level of support they receive (70%) and that improved support would positively influence their deci- sion to work in a community post (78%). DISCUSSION The issue of race must clearly be addressed when considering the use of ICT within university physiotherapy departments, with most Black students having access to ICT resources for the first time on entering university. Black physiotherapy students are therefore disadvantaged from the very outset of their studies, which leads to uncomfort- able questions about the possibility of student performance being racially dif- ferentiated if physiotherapy departments begin using ICT tools more frequently as part of the curriculum. This lack of access and equity in South African higher education was highlighted by Scott et al (2007) and confirms that much work is still to be done by higher education institutions, beginning with a need to quickly identify students who require extra support in order to make the most of ICT resources during their physiotherapy education. Respondents indicated a preference face-to-face contact as the means by which support could be accessed, which was in agreement with Rohleder et al (2007) who found a similar preference for face-to-face interaction between students and staff in higher education. When considered alongside the findings by Stiller et al (2007), who reported that Australian physiotherapists would pre- fer a model for clinical education that encouraged more, not less, face-to-face contact time, it seems that ICT should not be used to reduce face-to-face con- tact time, as has been suggested by Eksteen (2005). Most students reported using the Internet to find information for assign- ments and projects, and this was the most common use of ICT at university by a margin of more than 20%, which is in agreement with at least one UK-based study (Devitt & Murphy, 2004). The fact that students are using the Internet to find information should be seen as a positive step towards self-directed learn- ing. However, while students may be comfortable with finding information online, there was no indication of the quality or credibility of this information. When considered together with the reported low use of email at university, this suggests that South African physio- therapy students use ICT primarily as a means of finding information, rather than as a means of communication. Despite this low reported use, most stu- dents indicated that ICT can improve communication between lecturers and peers and felt confident to use it. While email has been shown to be a reliable, efficient and cost-effective means of communication, South African physio- therapy students do not use it as part of their studies, losing out on the potential of enhanced levels of engagement with each other and their lecturers. Although most students agreed that ICT could improve the level of support they receive, very few respondents Activity Confident Uncertain Not confident n % n % n % Internet search 441 83.4 21 4 10 1.9 Email 438 82.3 17 3.2 6 1.1 Printing documents 412 77.9 26 4.9 11 2.1 Writing letters/records 381 72 33 6.2 24 4.5 Preparing presentations 380 71.8 60 11.3 15 2.8 Professional development 376 71.1 69 13 18 3.4 Research 227 42.9 145 27.4 47 8.9 Games 225 42.5 44 8.3 14 2.6 Forum discussion 180 34 75 14.2 35 6.6 Exercise prescription 121 22.9 150 28.4 33 6.2 Discrepancies in percentage totals are a result of missing data Table 3: Physiotherapy students’ reported confidence in using ICT (N=529) 36 SA JOURNAL OF PHYSIOTHERAPY 2009 VOL 65 NO 3 reported using ICT tools to seek advice or guidance. This finding is in contrast to the literature, which has identified ICT as offering a means of both improv- ing communication and peer support (Johns, 2003; Rohleder et al, 2007; Mitchell et al, 2001). This highlights the potential to improve this aspect of communication between lecturers and students. This suggests that while South African physiotherapy students are aware of the potential of ICT to improve the support they receive, they do not actually use it. While it was beyond the scope of this study to investigate reasons for this, it may be that students only use the channels of communication that are available to them. It is a concern that research was high- lighted as the area in which more than a third of students were either “Uncertain” or “Not confident”. However, even though 83% of students reported feeling confident using the Internet to perform online searches, they did not make the connection between using the Internet to find information for assignments and using the same techniques to inform their education and practice through research. With a move towards self- directed learning practices in undergra - duate education (Oblinger & Oblinger, 2005), students may not have the insight to use the skills they possess to more effectively learn. The university attended was found to be a significant factor in the frequency and reasons for ICT use, with respon- dents at two particular universities using ICT resources more often and for a greater number of activities than respondents at other universities. This suggests that the university a student attends will influence both the frequency of ICT use and the activities they use it for. Thus, it seems clear that the role of the university is important both in terms of providing access to technology, as well as in better preparing students for it’s use. Two particular areas should be highlighted. With the evidence indi- cating that students’ use of ICT is focused on online search, universities should take measures to ensure that they are able to differentiate between high quality, credible information on the internet, and poor quality articles. The other area in which there is potential for improvement, is in communication, with universities opening up further channels for communication between students and lecturers. The results of this survey indicate that while South African physiotherapy students are aware of the potential bene- fits of using ICT as part of their studies, they do not always make the best use of them. The reasons for this discrepancy were not within the scope of this study, but may include the fact that not all institutions or departments facilitate or require students to use ICT resources. With the move towards the provision of physiotherapy community-based health services in rural areas where profes - sional support may be lacking, certain groups of South African physiotherapy students may be disadvantaged when it comes to the use of ICT in these envi- ronments. As a result of poor access to ICT prior to attending university, Black South African physiotherapy students in particular may struggle to take advan- tage of the benefits of ICT as a means of improving communication and access- ing support. While Coloured and Indian students also reported reduced access to computers and the Internet prior to attending university, this was not as high as Black students. CONCLUSION AND RECOMMENDATIONS The use of ICT has been shown to be a feasible means of improving the profes- sional education and support of physio- therapy students, mainly through improved communication and greater access to information. However, it is recognised that a shift to an ICT-enabled physiotherapy curriculum will bring with it several challenges, not least of which is the issue of racial differen - tiation in access and equity prior to attending university. The implications of this for South African physiotherapy education is significant, in that more attention must be paid to the needs of certain groups of students and the input they require, especially when using ICT resources. It was also shown that most South African physiotherapy students use ICT as a means of gathering informa- tion, rather than to obtain support through improved communication with educators, clinicians and their peers. It is recommended that physiotherapy departments at universities should develop and implement a comprehensive ICT strategy, focusing on the use of ICT to improve communication between stu- dents and lecturers. However, educators must be aware of the differences in ICT experience between some groups of students and adapt their teaching strate- gies accordingly. They must take cogni- sance of the fact that not all students have had the same advantages prior to entering university and that their teach- ing methodology cannot assume an even distribution of ICT experience. Educators should also aim to link the ICT skills that students already possess, to activi- ties related to their education and pro- fessional practice. Finally, universities must provide ongoing training for staff and students to make effective use of emerging technologies to enhance teaching and learning practice. REFERENCES African National Congress 1994 A National Health Plan for South Africa. 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