Perceptions of and attitudes to the compulsory Community Service programme for therapists in KwaZulu-Natal

The success of Community Service programmes initiated globally to recruit health care professionals to provide services in under-served or rural areas depends largely on their attitudes, understanding of the programme's objectives, prepared­ ness for working in these areas and their adaptability. This study assessed rehabilitation therapists' perception and atti­ tude on commencement and completion of their compulsory Community Service programme in KwaZulu-Natal in 2005. Repeat observational cross sectional studies were conducted. A self-administered questionnaire was completed by all therapists on commencement and after completion of their Community Service. The proportion of therapists who indicated that they would work in the public sector in future declined from 50% at onset to 35% by exit and fewer (24%) said they would work in a rural area. Collecting a rural allowance was not associated (p=0.78) with an expressed interest to work in a rural area or remain at the same institution (p=0.32). There were significant differences in support and supervision pro­ vided between the professional groups (p<0.001). Particular concerns centred on limited infrastructural support, supervi­ sion, training, resources available and language barriers in delivering a better rehabilitation service. Despite the challenges faced, Community Service therapists felt that they had made a difference and that their experience had been personally and professionally rewarding.

A major challenge facing South Africa is the provision of basic health care to all citizens and rectifying historical inequities in health service delivery.An increasing burden of disease and disability and the problem of recruiting and retaining health care professionals in rural and under-served areas makes providing equitable and quality health care more difficult to achieve.Some strategies have been developed glob ally to address the problem (Cavendar & Alban, 1998;Couper, Hugo, Conradie & Mfenya.J 2007;Reid, 2001;).These inlcude compulsory Community Service (CS) for physicians and other health care professionals jn these areas, where it is assumed that they will improve the' health status of rural populations.t South Africa adopted legislation for compulsory but remunerated CS in 1998 for medical and allied health professionals, which they have to complete before being permitted to practice in their respective professions (National Department of Health, 1998).The CS policy aims to promote and reinforce the provision of quality health care especially in rural, under-served areas and previously disadvantaged areas of the country.It is intended to redress historical imbalances in health care provision but also to create an opportunity for newly qualified professionals to de velop skills, acquire knowledge, behaviour patterns and critical thinking, to help them in their professional development (Reid, 2001).CS for rehabilitation therapists commenced in 2003 in the province of KwaZulu-Natal (KZN) and 142 therapists ( 69Physiotherapists, 43 Occupational Therapists and 27 Audiolo gists and Speech-Language Therapists) have undergone CS in the province.In order that CS programmes are successful and achieve their desired goals continual monitoring and evaluation of their implementation is recommended (Reid & Conco, 1999).Studies in South Africa focussing on CS for medical doctors, dentists and pharmacists (Maseka, Ogunbanjo & Malete, 2002;Omole, Marincowitz & Ogunbanjo, 2005;Reid, 2001Reid, , 2002)), reported that most of these professionals felt that they had positive experiences and improved peoples' health although supervision, mentoring, logistic and administra tive support was inadequate.A successful CS programme needs the supportive attitudes of health professionals, their understanding of the programme's objectives, their prepared ness for doing rural service and the ability to adapt to new and challenging experiences (Cavender & Alban, 1998).Health professionals deployed on CS in South Africa constitute a size able proportion of human resources in under-served areas.
They are important actors in the implementation, monitoring and evaluation of the CS policy as the programme directly af fects their personal and professional lives.Health personnel, unlike other resource inputs into the health system, are not passive role-players in the planning process.Their attitudes, perceptions and happiness may either promote or conflict with the objectives, goals and needs of the health service (Lehman & Sanders, 2004;Sanker, Jinabhai & Munro, 1997).The above understanding of the CS therapist's perspective and attitudes is essential and formed the rationale for this study.As key stake holders in the CS programme these therapists can provide valu able insights into the needs, successes and recommendations for improvement of the CS policy, ensuring sustained and im proved distribution and effectiveness of therapists in under served areas and ultimately in improved health for the commu nity.

METHOD
A repeat observational cross sectional study design was used to ascertain the attitudes and perceptions of rehabilitation thera pists to their CS experience in hospitals in KZN at two points in time, namely on commencement and after completion of CS.
These were then compared amongst the different occupational categories of therapists.All therapists undergoing CS in 2005 were included in the sample and answered a self-administered questionnaire on commencement and again on completion of their CS.The data collection was based on a previously validated questionnaire used to evaluate CS in physicians (Reid, 2004), and adapted with assistance from key stakeholders and piloted for therapists.The questions focussed on issues in CS such as the community outreach component, language difficulties experi enced and other topics specifically relevant to therapists in KZN.Some open-ended questions were included in the questionnaire to enhance the validity of the responses.Variables included biographical and demographic details, placement and occupa tional categories, understanding of the CS policy and objectives, attitudes, perceptions and preparedness of therapists to under take CS, adaptability to rural experience, benefits of the pro gramme both personally and professionally; and, finally, recom mendations for future CS policy and practice.
The commencement questionnaire was distributed at the an nual orientation and induction workshop and CS therapists were requested to complete the form immediately.The exit question naire and consent form was e-mailed to all the therapists at the end of the year's CS and receipt thereof was confirmed telephonically.Participants were encouraged to contribute to the study in order to improve the number responding and reduce selection bias.Completed questionnaires were returned by post, fax or e-mail.Non-respondents were followed up twice.Re sponses were made anonymously and data remained confiden tial.All data was cross-checked for completeness, legibility and consistency and collated in EPI-INFO.After data was cleaned and coded it was processed and analysed using SPSS.Data was summarised using frequency distribution tables and appropriate graphs.The statistical significance of associations between cate gorical variables was assessed using Chi Squared tests.The Nasim Banu Khan, Stephen Knight and Tonya Esterhuizen attitudes and perceptions of CS therapists were scored on a scale of 1 to 4. Questions were grouped into common themes, weighted and scored by summing across the items to generate a score for each theme.These continuous numeric scales were analyzed quantitatively.Comparisons1 were drawn between groups using independent t-tests (in the case of two groups such as gender) or ANOVA (in the case of more than two groups such as occupational category) with Bonferroni post hoc multiple com parison tests also being employed.McNemar's Chi Square tests were used to assess the statistical significance of any differ ences in the proportion of perceptions and attitudes reported from pre-to post-CS (using p < 0.05 as the cut off for signifi cance).Ethical approval was granted by the University of KwaZulu-Natal, Biomedical Research Ethics Committee and permission for the study to be conducted by the KZN Depart ment of Health.

RESULTS
The commencement questionnaires were distributed to 142 community service rehabilitation therapists and 126 (89%) com pleted the initial questionnaire, but only 59 (42%) completed the exit questionnaire.A third (47) of respondents completed both the initial and exit questionnaire.Therapists were placed at 59 gazetted sites in under-served areas2, of which 32 (54%) were situated in rural3 areas (Table 1).
M e a n score = average o f responses to ordinal categories for purposes o f comparison between the profes sions.The higher the score, the higher the chances were that they were likely to change their plans as opposed to oth er professionals.
2A site refers to all hospitals where therapists were placed for C& The South African government published the names o f 59 hospitals in KwaZulu-Natal where therapists could apply to complete their CS.
3Rural sites are defined as hospitals where health care practitioners are a/located a m onetary incentive for working (ruml allowance).Reproduced by Sabinet Gateway under licence granted by the Publisher (dated 2012.)It is important that young professionals are supported and mentored during their CS in order to develop skills and compe tencies to enhance their professional and personal develop ment.At the onset of CS, most rehabilitation therapists (66%) believed that they would be furnished with adequate support and supervision to be able to function optimally during their CS year.Sadly, most felt that this was not provided.Overall there was no significant difference in mean supervision level or men toring between the occupational categories of therapists.The therapists working in the public sector are affiliated to the KZN Professional Fora of Speech Therapy and Audiology, Occupa tional Therapy and Physiotherapy.These operate under specific terms of reference and a mandate from the Department of Health that recognizes their contribution to the health service, for persons with disabilities and those at risk, in the province.
Each forum meets quarterly in the province to discuss issues relating to their particular professional occupational category.
When the mean level of support was compared between the professions with regards to the most satisfactory support from their professional forums, a highly significant overall difference Reproduced by Sabinet Gateway under licence granted by the Publisher (dated 2012.)Nasim Banu Khan, Stephen Knight and Tonya Esterhuizen ended questions supported the contention that CS therapists enjoyed no, poor, or inadequate supervision and that they were the sole therapist in the hospital to which they had been allo cated.Perceptions of the adequacy of support and supervision had deteriorated during the year of CS.Overall, the majority of CS therapists 67% (37/58) agreed that senior health profession als at the hospital were not perceived to be of assistance to them or otherwise supportive.
In relation to resource availability there was no difference be tween the occupational categories of CS therapists in how they assessed the space allocated for working, availability of trans port to perform community work, parking space for their cars or residential accommodation (p = 0.536, 0.295, 0.799, 0.508 respectively).In their responses to the open-ended questions, some therapists indicated that they had found it difficult to ac cess resources to perform adequately.Some used their own resources or secured private sponsorships for basic equipment.
In many hospitals, there was no specified budget for therapy or basic equipment required to support the practice of each occu pational category.When a new therapy service needed to be established in a hospital, it took a very long time to finance the set-up costs.CS therapists also reported that they required more culturally appropriate therapy resources, especially for isiZulu speaking clients.
Most therapists in KZN have English as their first language, with little or no isiZulu which constitutes an impediment in com municating with the majority isiZulu speaking clients.There is a clear need for interpreters, yet these were not always trained in discipline specific translation or interpretation.Even with an interpreter, 33% (19/56) found it difficult to undertake therapy satisfactorily and half claimed that the language barrier impeded their functioning as a therapist in this context.Audiologists ex perienced the least difficulty (p=0.037) and Occupational Thera pists the most difficulties.However, the individual differences between the occupational categories was not statistically signifi cant (p=0.068).
In KZN, 40% of CS therapists' time should involve providing community outreach rehabilitation services in clinics throughout the health district to facilitate improved access to rehabilitation therapy services for disabled people in the community.There was no difference between the occupational categories with regard to the amount of community outreach they were able to perform (p=0.347).More than half the CS therapists (31/57) felt that they had succeeded in their endeavour of providing sub stantial community outreach.Only a quarter (15/57)) believed that they had failed completely to conduct any community out reach and 20% managed to conduct at least some communitybased rehabilitation services.Speech-Language Therapists man aged to conduct more community outreach than Occupational Therapists (p=0.450).Analysis of the open-ended questions revealed that many therapists were able to conduct regular clinic visits but that this remained limited due to the huge caseloads prevailing at hospitals, poor clinic infrastructure, transport prob lems and the poor turnout of clients at the clinics.
Questions on whether therapists believed they coped psycho logically were formulated due to the anxiety expressed by some therapists and their relatives prior to commencing CS.There were no occupational specific differences (p=0.678).All the occupational categories felt that they had made a difference to service delivery and had gained both personally and profession ally from their CS year, despite initial concerns about the logis tics and possibly unrealistic expectations of the compulsory CS year.
Career plans were assessed to determine whether CS had made a difference to participants intentions to become public service employed rehabilitation therapists in the future.No sig nificant difference existed between the categories (p=0.832).
However, 56% (n=31/56) of therapists agreed that having com pleted a year of CS did not change their initial plans to leave the public sector.The analysis of the open-ended questions showed varied responses with some claiming that the experience of CS had negatively influenced their plans to change careers and that the experience was both de-motivating and unpleasant.Other therapists felt that it had changed their work ethic positively.Some reported that they had possessed no choice because of the necessity of fulfilling their bursary obligations to work in the province in their CS year.Overall only 16% (n=9/59) of the CS therapists who completed the exit questionnaire indicated that they would stay on at the same institution during the next year.
These therapists had enjoyed the positive working environment, the level of support they received and their exposure to a varied caseload.Approximately 41% (n=24/59) would consider their hospital a place to work in future.Most therapists indicated that they would recommend their allocated hospital as suitable for future CS placement.One of the objectives of CS is to attract and retain therapists in rural areas.Only 24% (n=13) affirmed I that they intended to work in a rural area in the future.Another i retention strategy adopted by the Department of Health involved the provision of an allowance to health workers if they worked in a rural area.There was no association (p=0.782), between therapists collecting a rural allowance and planning to work in a rural area in future, although those placed'in urban areas did indicate that they would be more likely to work in rural areas in the future (p=0.018).There was also no association between collecting a rural allowance and remaining at the same institu-/ tion in the future (p=0.317).Those (n=31) collecting a rural al lowance had a lower mean score (2.10) than those who were not  (Couper, Hugo, Conradie & Mfenyana, 2007, 2005;De Vries & Reid, 2003;Hall, 2001;Maseka, Ogunbango & Malete, 2002;Sankar, Jinabhai & Munro, 1997).
In KZN, training must be relevant to CS delivery needs where most therapists serve district hospitals and are required to pro vide a substantial time serving the community at primary health care clinics.This study, like other South African studies, revealed poor support and supervision for CS therapists by peers, more senior therapists and hospital management especially in rural areas and district hospitals where problems may be more com plex and intractable.Ongoing support needs to be available for induction, orientation, mentoring, support and supervision of CS therapists.Regular Professional Forum meetings were found to offer good support and opportunities for mentoring.
Appropriate resources are needed to provide a quality service, I and this is especially so a t sites where a new therapy service is , i being established.The barijier to service delivery afforded by the lack of resources has been identified in similar studies (Reid, 2001;Cavender & Alban, 1998).Occupation specific essential equipment, adequate space to work, transport for community outreach and the provision of living accommodation should be non-negotiables in a CS programme and should be linked to im proved conditions of service and budgeting for the service.The language and cultural challenges limited the ability of CS thera pists and other health professionals to provide a quality service in under-served areas.(Reid, 2001;2002).In addition to having appropriately trained and resourced interpreters, all therapy train ing institutions and the health department need to undertake extensive language training to equip therapists for CS and to work effectively in this multi-cultural and multilingual society.An expec tation that CS therapists expand their service to clinics and to the community is unique to this category of health care worker in KZN.It has been identified as a way to strengthen disability and rehabilitation services at district level.Although a relatively re source intensive policy, it has the potential to provide an effective and professional community outreach disability and rehabilitation service and also should be pursued by other cadres of health care professionals conducting their CS programmes.
A major challenge is the proportion of therapists who, having indicated that they would remain or intended to become public sector employees and work in a rural area, declined following the experience of compulsory CS.A rural allowance did not prove an incentive to work or remain in a rural area, a finding confirmed by other similar exit-interview studies done with South African doc tors.(De Vries & Reid, 2003).In addition to improving training, support and supervision, resource allocation, language and re sources for community outreach, other recommended strategies that could motivate therapists to work in the public sector, espe cially in under-served areas (Hall, 2001;Reid, 2004) include be ing granted approval to conduct private practice outside public service hours, increased vacation leave, improved working condi tions, opportunities for post-graduate training, better rural living conditions, creating more posts in rural areas and financial incen tives other than rural allowances.An inter-sectoral forum needs to be created to effectively address challenges impacting on CS programme implementation.The CS rehabilitation programme should be sensitive to needs which are identified in continuous monitoring and evaluation in order for it to be more responsive to changes required in policy and practice.
This study proved useful in identifying areas of need and suc cess in the implementation of CS for therapists in KZN.It also provides information that can be used by the managers of the programme and other key role players to improve future CS for therapists and other healthcare workers in KZN.

CONCLUSION AND IMPLICATIONS
Therapists found the CS experience both personally and profes sionally rewarding.However, if community service therapists and health care professional are to be retained in rural and under served areas, there need to be substantial structural adjustments in the health system including improved administration, manage ment, supervision, mentoring and logistical support.CS policy should be evaluated and monitored regularly and the findings and recommendations used to inform policy development and assist implementation of the programme.
The study has some substantial methodological limitations which could affect the validity of the findings.Certain questions in the onset and exit questionnaire were not comparable.Reproduced by Sabinet Gateway under licence granted by the Publisher (dated 2012.) the Audiologists and Speech-Language Therapists -knowing that the principal investigator was from that occupational category.
Ultimately the question is, whether compulsory CS, which in creases the presence of health professionals in rural and under served populations, impacts on the quality of life of persons with disabilities and those at risk.Further investigation, that ensures internal and external validity comparing therapists that remain in the public sector and/or in under-served areas and those that leave after the completion of CS is required.This would contrib ute to understanding why therapists remain or leave.Issues re lated to training (undergraduate and in-service), supervision and ongoing support of junior therapists also need further investiga tion and discussion.
Perceptions of and attitudes to the Compulsory Community Service Programme for Therapists in KwaZulu-Natal Changes in attitudes and perceptions of therapists from onset to exit from CS were measured.Four of the attitudes and percep tions of therapists changed from negative or neutral at onset to positive or remained positive from onset to exit of their CS.An improved understanding of the CS policy occurred in 87% (13/15) (p=0.052) and perception of the availability of informa tion on policy, procedures and guidelines occurred in 72% (18/25) of therapists (p=0.036).A significant (p=0.006)propor tion (20/31-65%) of therapists who initially disagreed or were neutral at onset regarding the availability of information about a hospital orientation, reconsidered their perceptions to agree that information on hospital orientation was available to them.At onset, 86% (38/44) of the CS therapists indicated that they were not resentful or upset about the site to which they were allocated and, at exit, 93% (41/44) maintained that they would recom mend future placement at the site (p =0.683).A number of attitudes and perceptions of therapists worsened during CS.Training was assessed to determine if therapists felt that their tertiary education equipped them with the necessary skills, competencies and knowledge to be able to perform CS effectively.There was a 36% (17/47) reduction in perception that their academic and professional training had equipped them for CS (p=0.281).Supervision and support were recog nized as important requirements for the professional develop ment of young health professionals undergoing CS.Initially, two thirds (31/47 -66%) of CS therapists anticipated that they would receive good support and supervision from senior peers and mentors.This perception had declined significantly (p=0.002) with only 34% (16) feeling that they had experienced adequate^ professional, discipline specific supervision during the CS year.One of the concerns expressed by therapists providing CS ini yolved the question of their personal safety.At exit, more (43% vs. 28% -p=0.239)felt thiat CS had increased their personal safety risks.The study also compared the therapists' intentions to remain in the public sector at onset to that of working in the public sector in subsequent years, after CS.The intention to work in the pubic sector declined from 50% (24/48) at onset, to i only 35% (17/48) at exit.Others expressed interest to work in other sectors with 29%, (14/48) indicating the private sector, 19% (9/48) overseas and 17% seeking alternate work outside the public sector.During the year of CS, the perceptions that therapists made a positive contribution to persons with a disabil ity or those at risk did not vary much from onset to exit with therapists generally remaining positive about their contribution to improving the health status of their clients.The attitudes and perceptions amongst the different occupa tional categories were also assessed.Tertiary education and training received, support from hospital managers, supervision and mentoring by peers, |availability of resources to practice professionally, outreach service obligations, language and work ing with interpreters, general attitudes and coping, personal safety, personal and professional gains, and future career plans were all investigated and compared.The data for this objective was obtained from 59 therapists who completed the exit ques tionnaire.A continuous numeric score was devised from cate gorical variables in order to compare the responses.Having completed a year of compulsory CS, 56% (33/59) of therapists felt that their undergraduate training was adequate and that they were well equipped to work in an under-served or rural area of KZN.Perceptions of the adequacy of training had deteriorated during the year of CS (3.82, p=0.281).There were no significant differences between the occupational categories in relation to perceptions about the adequacy of training at e x it.In the open-ended question analysis therapists indicated that they needed to have acquired more skills and expertise concern ing management and administration of health facilities during university training.Of those who perceived that their training was insufficient or inappropriate, the ability to speak the local lan guage (isiZulu) in order to perform professionally, and under standing of cultural issues were aspects specifically mentioned as being lacking in their training.Therapists were of the opinion that their training needed to cover administrative aspects and involve more practical experience at rural and under-served loca tions.There were clinical areas that therapists felt they needed additional training on, for example Speech-Language Therapists and Audiologists cited special tests for audiology (Auditory Brain stem Response Testing), dysphagia, pseudohypacusis, cerebral palsy and neonatal intensive care-particularly neonatal feeding.
was found between Audiologists and Speech-Language Thera pists, and other therapy groups (p=0.002).Analysis of the open-THE SOUTH AFRICAN JOURNAL OF COMMUNICATION DISORDERS, VOL 56, 2009 19 collecting one (n=24; mean= 2.38), indicating that those work ing in rural areas and concurrently collecting a rural allowance were less likely to stay at the same institution in the future.20 DIE SUID-AFRIKAANSE TYDSKRIF VIR KOMMUNIKASIE-AFWYKINGS, VOL, 56, 2009 Reproduced by Sabinet Gateway under licence granted by the Publisher (dated 2012.)Perceptions of and attitudes to the Compulsory Community Service Programme for Therapists in KwaZulu-Natal DISCUSSION AND RECOMMENDATIONS The current study confirms both national and international sup port for compulsory CS as a strategy for the recruitment of health care professionals to under-served and rural areas.However, CS needs to be implemented together with other financial and nonfinancial strategies if it is to lead to sustained improvements in under-served and rural areas.These should include training, su pervision and mentoring, resources, language difficulties, com munity outreach and other challenges.Numerous factors influ ence the deployment and retention of health professionals in rural areas including the appropriateness of undergraduate train ing, curriculum review, exposure to practical training in under served areas, functional literacy in local languages, preferential selection of therapists from rural backgrounds and granting bur saries to study in health sciences All CS therapists in 2005 were included in the sample in order to reduce selection bias, however the low response rate for the question naire and the large drop-out rate of respondents from onset to exit of the CS year introduced a selection bias.The resulting small sample size also affects the accuracy of the results.Many differences observed require cautious interpretation especially where statistically significant associations were not found.A so cial desirability bias could explain more favourable outcomes for THE SOUTH AFRICAN JOURNAL OF COMMUNICATION DISORDERS, VOL 56, 2009 21

Table 1 :
: Occupational category, gender and placement site of community ser vice therapists completing both initial and exit questionnaires in Kwazulu Natal in 2005 .