Involvement in and Views on Social Responsibility of Gauteng Members of the South African Society of Physiotherapy : A Cross-sectional Survey Corresponding

Corresponding Author: Karien Mostert­Wentzel PO Box 223, Newlands, Pretoria 0049 South Africa E­mail: karien.mostert@up.ac.za AbSTrAcT: How do physiotherapists in Gauteng Province, who are members of the South African Society of Physiotherapy (SASP), view social responsibility? A cross-sectional survey was conducted after ethics approval. All 1 098 Gauteng members of the SASP were invited via a thirdparty e-mail to reach the a priori minimum sample size of 97. The web-based questionnaire was developed from literature, an earlier SASP survey and a position paper of the American Physical Therapy Association (APTA). Five experts validated the instrument. The Likert scale scores indicating agreement with indicators of social responsibility were totalled to form a composite social responsibility score. The chi-square test for independence was used to determine associations between the categorised composite social responsibility score and categorical variables. mean difference of continuous variables between the categorised core for two groups were tested using the two-sample t-test. All variables with a P-value less than 0.05 were included in the logistic regression analysis to investigate predictors of the necessity of social responsibility. The survey was completed by 163 participants. of the sample, 96.9% viewed social responsibility as important. Subjects agreed most with “advocating for the health needs of society” (74,2%) and the least with “political activism” (6.1%). Compulsory community service positively influenced 74.6%. most physiotherapists in the study viewed social responsibility as important and were involved in volunteering. There is scope to broaden the understanding among physiotherapists of what social responsibility entails.

terment of society.The duty towards social responsible practices is especially topical in a country like South Africa where training in healthcare profes sions is subsidised by government.In fact, physio therapists do not only have a responsibility towards themselves and their patients, but also to the broader community to meet society's present and future needs (Fricke 2005).In light of tensions within social responsibility e.g.balancing monetary gain to make a living, with addressing the needs of vulnerable groups in society do indi vidual physiotherapists support the notion of social responsibility?
Three common themes about social responsibility were found.These themes

INTRODUCTION
Society grants professionals autonomy in decisionmaking and selfregulation.Society also recognises and accords physiotherapists, as other health profes sionals, "a special social, moral, and political status as a profession" (Dha ramsi et al. 2007, p 1,591).In turn for these societal benefits, professionals have an obligation towards the bet are, first, that social responsibility is a basic concern for what is right regard ing social and ethical issues (Witt and Silver 1994).Second, social responsibi lity is a commitment to the pursuit and achievement of a valued end, e.g.human health and welfare (Weed and Mckeown 2003).Third, social responsibility is "the promotion of a mutual trust between the profession and the larger public that necessitates responding to societal needs for health and wellness."(American Physiotherapy Association (APTA) 2004, p. 4).
Social justice addressing inequities in health care is fundamental in the drive to the revitalisation of primary health care services (Commission on Social Determinants of Health (CSDH) 2008), as well as for broader develop ment (United Nations Department of Education and Social Affairs 2005).Inequalities include those between the developed and the upcoming world, between rural and urban areas, between the poor and the privileged, between females and males, and also between those with disabilities and those without (World Health Organization (WHO) 2008).
From before 2003 the South African Society of Physiotherapy (SASP) took a lead at national level to actively pro mote the initiative that physiotherapists, along with other cadres of health work ers, complete a compulsory service year in the public sector after graduation.This policy initiative directly aims to improve access to health care.In addi tion, the SASP conducted a survey in 2008 on social responsibility (South African Society of Physiotherapy 2009).It investigated the nature, extent and set tings of voluntary services offered by its members.Although the recruitment rate of the survey was low, the findings indicated that the majority of those who responded to the survey were willingly undertaking services in communities.
The views of Gauteng physiothera pists on the elements of social respon sibility as advocated by APTA have not been determined, as far as the research ers could establish.This article describes a study to determine these views of Gauteng members of the South African Society of Physiotherapy, as well as practices showing social responsible behaviour.Findings from this study could serve as a reference point for the further evolution of socially respon sible physiotherapy practice as part of ethical health care in the province.

Study design and ethics clearance
This quantitative webbased cross sectional survey received approval from the Faculty of Health Sciences' Ethics Committee, University of Pretoria (UP) (Reference S36/2010).
Academics from five universities, known to the researchers, who were knowledgeable about physiotherapy, health sciences education (an education consultant and fellow of the Southern African Faimer Regional Institute (SAFRI)), community engagement (first author of a book on servicelearning) and/or questionnaire development validated (academic with a PhD), scru tined a version of the survey that was emailed to them.One of the reviewers commented that volunteering received too much attention.This section was, however, kept, as it was the part from the earlier SASP survey.Five physio therapists from provinces other than Gauteng piloted the survey.They understood the questions and did not experience technical problems like dif ficulty logging in to the survey system.

Data collection
The link to the survey was provided only to members of the SASP in Gauteng Province.The survey option that pre vented the capturing of respondents' IP addresses1 was used to ensure ano nymity.
To optimise the response rate an email was sent as a reminder to all participants two weeks after the initial one (Fan and Yam 2010).Opportunity to participate was allowed for two more weeks.The survey was therefore acces sible for four weeks in total.

Data capturing and analysis
Results captured in SurveyMonkey were exported to Microsoft Office Excel 2007 and imported to STATA 11 for analysis.Descriptive statistics consisted of fre quency tables for categorical variables and means and ranges for continuous variables.The Likert scale scores that assessed agreement with the indicators of social responsibility were totalled to form a composite social responsibility score.Higher composite scores indicated higher levels of agreement with the indicators of social responsibility.The composite score was divided into two subcategories, with score less than 20 indicating low level of agreement and the score above

Study population and sampling
Of the 5 410 physiotherapists registered with the Health Professions Council of South Africa (HPCSA), 1 926 had addresses in Gauteng Province.Of these 1 098 were members of the SASP and all were invited to participate.Logistically a focus on only one area of South Africa was feasible.Gauteng was appropriate as it has the greatest concentration of physiotherapists com pared to other provinces.

Instrumentation
The researchers compiled the question naire from a conceptual framework developed from a literature review, incor porating elements from the SASP survey and APTA indicators of social respon sibility (APTA 2004).The question naire had three sections: Demographics, Views on Social Responsibility, and Involvement in Volunteer Work.
A multiplechoice question that indi cated clearly that more than one option could be selected, tested the subjects' definition of social responsibility.Five scale Likerttype questions assessed subjects' views on the necessity of social responsibility, the influence of the compulsory community service year on these views, and the level of agreement with statements about social responsibi lity.Various aspects of subjects' involve ment in voluntary services, practices reflecting one aspect of social respon sibility, were also asked about.A senior teacher of Afrikaans Language translated the questionnaire into Afrikaans from English.In turn, a teacher of English Language translated the Afrikaans questions back into English to ensure that the original meaning was kept.
The questionnaire was administered using a webbased survey tool, Survey Monkey.The survey started with infor mation about the study so that subjects could consent to participate or not.The survey's 25 questions were presented over six screens.None of the questions were mandatory and parti cipants could exit the survey at any point.Subjects were routed to dif ferent questions in accordance with their responses.20 indicating high level of agreement.The chisquare test was used to determine associations between the composite score groups and cate gorical variables.Mean diffe rences of continuous variables for two groups were tested using the two sample ttest.All variables with a P value of less than 0.05 were included in the logistic regression analysis to investigate predictors of a high level of agreement with the indicators of social responsibility.

Characteristics of the sample
The recruitment rate was 20.1% as 221 of the 1 926 members of the Gauteng branch of the SASP viewed the first page of the survey.Of these, 163 (73.8%) completed the questionnaire.Table 1 shows the demographic profile of the sample.The majority were females accounting for 92%.Most participants, 127 (77.9%), had a Bachelor's degree as their highest qualification.The average age was 38 years, ranging from 23 to 72 years.The number of years participants have been practising as physiothera pists ranged from less than one year to 51 years with an average of 14 years.Different settings where physiothera pists work included private practice, private hospitals, state hospitals, rehabi litation centres, sports centres, commu nity projects and other work settings.Of the participants, 63.8% indicated that they worked in only one type of setting, and 28.2% worked in two settings.

Views on social responsibility
The results showed a mixed response about the definition of social responsi bility (Table 2).Only 17 (10.4%)chose all three of the descriptions of social responsibility: (1) A concept which is based on a basic concern for what is right regarding social and ethical issues, (2) The promotion of a mutual trust between a profession and the larger public or society that necessitates responding to societal needs, (3) A duty owed to the public/society to further human welfare (although it is not a duty to fully meet com munity standards or the expectation of society).The majority (96.9%) viewed social responsibility as a necessity.Of the 61 (38.6%) subjects who had completed a compulsory community service year, 44 (74.6%) answered that the year had a positive influence on their view of the value of social responsibility.
Table 3 gives the findings of the level of agreement with each of the APTA indicators of social responsibility.The majority of the respondents agreed with most of the indicators.Subjects agreed mostly with "advocating for the health needs of society" (74,2%).However, less than 50% agreed that physiothera pists have a role in "promoting com munity volunteerism," "participating in the achievement of social health goals" and "providing leadership in the com munity."Only 6.1% agreed that physio therapists should "sometimes to always" "participate in political activism."

Involvement in voluntary work
The majority of subjects, 119 (77%) were involved in voluntary serv ices, and 89.1% found their involve ment rewarding.Of the sample, 49, (41.5%) spent between zero and three hours per months in voluntary work, and 32.5% stated the cost of between R0 and R249 to carry out voluntary work.Table 5 shows the factors that were considered for involvement in volunteering.
Of the 35 (23%) who were not involved in voluntary services, 16 indi cated that they would like to volunteer.According to two respondents, volun tary service does not fall in the scope of physiotherapy practice.One said that it was too timeconsuming; another that enough voluntary services were offered by others, and another was involved in charity work not related to the profession.
The settings where voluntary services were offered can be seen in Table 6.Of the participants, 58.5% were involved in one type of voluntary work, while 26.3 offered voluntary services in two different settings.The settings where physiotherapists offered voluntary ser vices were spread across different areas, with 26.1% offering services at schools and 23.5% at sports clubs or sports events.

DISCUSSION
The purpose of this study was to mea sure Gauteng SASP members' views on and involvement in social respon sibility.The majority were in agreement with indicators of social responsibility, and were involved in volunteering.
The esurvey recruitment rate (20.9%) was slightly higher than in the 2008 SASP survey (12,9%).A larger propor tion of the current study respondents completed this study (73.8% versus the SASP's 54.2%).The demographic pro file of the sample is in agreement with the province's physiotherapy population in terms of gender.(Eleven per cent of the Gauteng Province SASP mem bers are male and eight per cent in this study.)Information on other demo graphic variables of the Gauteng popu lation could not be obtained.
The study confirms the general find ings of the 2008 SASP survey as two thirds identified social responsibi lity as important, and even a necessity.Dharamasi ( 2007) had similar findings.
The basic premises of ethical beha viour underpin all six indicators of social responsibility that subjects agreed with most.These premises are justice (e.g.advocating for access for all), benefi cence (e.g.ensuring that policies are in the interest of clients), nonmaleficence (e.g.understanding and taking into account the complex context in which physiotherapy services are delivered and the social factors that influence each individual client) and autonomy (e.g. by respecting patients' values and experiences by acting in culturally appropriate ways).As can be expected, stu dies with other cadres of health workers found the same foundation for socially responsive practice (Weed and Mckeown 2003;Furier and Palmer 2010).
Regarding further understanding of what social responsibility means, few subjects included all three elements of the definition in the survey: concern for doing the right thing, working toward society's health and wellness, and building cooperative relationships with society.This less than optimal view was mirrored in the response to the APTA indicators; two thirds did not regard political activism as a socially respon sible practice.Activism is often the mechanism to influence policymakers and to achieve other aspects considered part of social responsibility.Free health services for persons with disabilities were an extension of policy of free services for mothers and children up to six years of age, realised to a large extent through activism from Disabled People Organisations, but also health workers.Similarly, less than half of the participants in a study in Mpumalanga province selected "advocating for pro vision of basic needs, like housing", and "mediating between different sectors for provision of service" as physiotherapy roles at primary care level (Maleka, Franzsen and Stewart 2008:4).
Correspondingly, the proportion of respondents who reported that they had given individual assessments and treat ments as part of volunteering are more than the combined proportion engaged with education and talks in both the current survey and the one in 2008.These findings may mean that physio therapists in Gauteng have not suffi ciently embraced a public health strategy within a primary health care approach.Primary health care underlines client empowerment through training and self responsibility for wellness, and public health puts emphasis on preventing injuries and disease at community level rather than on treatment of conditions once they occur.
As in 2008 (SASP) the settings where voluntary work is done is a mix of com munity and clinicallybased settings with the most prevalent ones being schools, old age homes, clinics, hos pitals and sports clubs.Unfortunately, similar international surveys could not be found.The current study confirms the established commitment of Gauteng physiotherapists to pro bono work.
The proportion involved in the "buddy"support system for community physiotherapist was 35% of the current sample, compared to six per cent in 2008.Two explanations are put forward for this increase.Either Gauteng physio therapists are more involved in mentor ing young colleagues than the country as a whole, or the overall number of physiotherapists involved in mentoring young colleagues has increased.This possible increase may be due to more awareness about the scheme.
The mainly positive impact on the atti tudes, because of the compulsory commu nity year, is encouraging.Through this service newlygraduated physio therapists contribute to more accessible health care in South Africa.Although young doc tors had serious complaints about health management, they also tended to find the compulsory year rewarding (Reid 2001).The WHO (2010, pp. 25, 26) advocates for mandatory service as one strategy to improve access to health in rural and remote areas.2Such schemes vary from one to nine years, and have been implemented, now or previously, in 70 countries.Also, rural placements during undergraduate training can significantly increase medical students' level of social responsibility towards the rural popula tion (Shannon et al. 2005). 1 A reason for this effect may be that students are exposed to the real needs and conditions of clients in their respective communi ties during these placements.
Likewise, the age group below 35 years tended to be keener towards social responsible practice than other age groups.This fact may be explained thereby that themes such as the social determinants of health and professional issues have received increasing attention in curricula at South African universi ties over the last decade.The amount of communitybased training has also increased; supporting evidence 1 that suitable training is successful in retain ing health workers in resourcepoorer communities, like those in rural and remote areas (Kaye et al. 2010;Strasser and Neusy 2010).

Limitations
Due to the nature of a quantitative sur vey, only a superficial perspective of how the concept is seen by physiotherapists was reached.Also, the questionnaire asked proportionally too many questions about volunteerism, which is rather a characteristic of altruism than of social responsibility.
Nonresponders could not be compared to the sample as similar demographic information was not readily available.Findings may therefore be an over estimate of importance of social respon sibility, as those who were not interested probably did not participate.Another limitation is that during analysis, the responses could not fully be categorised into private or state work settings, as the subjects were not asked to specify the sector when selecting rehabilitation or sport centres as a work facility.
Furthermore, the findings do not reflect the views of all the physiotherapists in the Gauteng Province, as only members of the SASP were invited to participate.The article also does not do justice to the actions already taken by the profes sional society, and by other groups to which physiotherapists may belong, like Equinet.

Influence of community service year on views about the value of social responsibility (n=59)
a Subjects could select more than one option

Table 3 . Level of Agreement with the APTA Indicators of Social Responsibility tested on a Likert Scale (N=163) indicator Agreement with each statement (Row %) completeness rate (cR) a Frequency (Row %) cR a Rarely to never Occasionally Sometimes to always
a Completeness rate = proportion of the total sample who answered this question

Table 4 : univariate Predictors of Agreement with the indicators of Social Responsibility Variable P value
Since the other variables were not signi ficantly related, only age was included in the logistic regression.Results showed that for a one year increase in age, there is a 3% increase in the odds of having a low social responsibility score [odds ratio = 1.03; 95% confidence interval (1 ; 1.06)].

Table 6 : Settings and Types of Voluntary Services Offered a n (%) Settings for offering voluntary services
a Subjects could select more than one option.