Knowledge , perceptions and attitudes of final year Medical , Occupational Therapy and Sport Science students regarding Physiotherapy , in KwaZulu Natal

Corresponding author: Prof. T. Puckree Faculty of Health Sciences Durban University of Technology PO Box 1334 Durban 4000 Email: puckreet@dut.ac.za AbSTrAcT: Knowledge, perceptions and attitudes about physiotherapy has affected its status. In a developing profession whose patient base is still significantly dependent on referral from medical practitioners, certain stereotypic attitudes about it require attention. This study investigated the knowledge, perceptions and attitudes of the 2009 final year medical, occupational therapy and sport science students at one university in KwaZulu natal, regarding physio therapy. A saturation sample of 292 students from the selected groups was invited to participate in the study. The cross sectional survey used a questionnaire with open and closed ended questions. The data was reduced to percentages and analysed using chi square tests at p< 0, 05. The overall response rate was 51% with 95% occupational therapy, 71% sport science and only 31% medical students responding. About 74% of the respondents had adequate knowledge about physiotherapy. Seventy five percent of medical and 50% of oT students knew that physiotherapists were first contact practitioners. over 50% of the respondents who had experienced physiotherapy displayed positive attitudes and felt that physiotherapy was a good career choice. Massage was the best known (95%) and electrotherapy the least known (44%) modality. orthopedics (88%), sports physio therapy (84%) and rehabilitation (78%) were better known. we conclude that the response rate to the study especially by medical students is of concern despite the overall positive attitudes displayed by the participants.

therapists are aware that doctors do not have an adequate knowledge and understanding of physiotherapy. Harris (1992), almost two decades ago reported that some patients have shown dis satisfaction with medical practitioner's lack of knowledge of physiotherapy services and the availability of alter native services. More recent evidence (Holdsworth et al 2008) suggests that general medical practitioners recog nize physiotherapists as complement prac titioners for the management of mus culoskeletal conditions.
If the public and related health care practitioners are ignorant about the role of physiotherapy in health care, recognition and professionalization will continue to be hampered and the rapy will be sought from alternate care practitioners. Kallus et al (1999) believe that because the public is not really clear about the services offered

INtRODuCtION
The recognition of a profession is dependent on the knowledge, attitudes, and perceptions of the public and stakeholders (Dalley and Sim 2001). Generally these attributes are developed based on exposure to practices by the professionals. Despite the growth in the evidence base, scope of practice through research and a real demand for servi ces, physiotherapy is still struggling to achieve status and be recognized as an essential service within health care. This is reflected in the remuneration package for public sector physiothera pists in South Africa (South African Society of Physiotherapy 2009).
Medical and health care professionals and the public have inaccurate percep tions based on inadequate knowledge which affect their attitudes towards physiotherapy (Harris 1992). Kenny and Adamson (1993) found that physio by physio therapists these profession als have suf fi cient reason to determine what the public and other health care professionals and students truly know about physiotherapy.
Several dated and recent international studies, have examined the knowledge, attitudes and perceptions of physio therapy by doctors and medical students (Silva et al 1981, Stanton et al 1985, Kenny and Adamson 1992, Lee and Shepard 1998, occupational therapists (Parker and Chan 1986), physiothera pists (MilesTapping 1992) physical therapy students (Turner 2001), general college students (Prati and Liu 2006), nurses (Dalley and Sim 2001), health science students (Hawk et al 2002, Hind et al 2003, high school learners (Kallus et al 1999, Ogiwara andNozoe 2005), and the public (LunaMassey and Smyle 1982, Parker and Chan 1986, Sheppard 1994, Summers 2003. A single study in the South African literature (Naidoo and Buhler 2009) examined the knowledge, attitudes, and perceptions of EThekwini district chiropractor and physiotherapy students about each other's roles.
The South African Society of Physio therapy markets the profession vigo rously and has implemented several strategies to achieve recognition for the profession (South African Society of Physiotherapy 2009). However, only the identification of critical contributory factors will assist in implementing the most effective public relations strate gies. Ultimately it is the responsibility of every physiotherapist to show the public that physiotherapists are truly first line practitioners and capable of both making and receiving referrals. The purpose of the present study was to determine the knowledge, attitudes, and perceptions of medical, occupational therapy and sport science students in KwaZulu Natal regarding physio therapy and identifying the factors that may play a role in improving recognition of the profession.

MEtHODS
A cross sectional survey with qualitative and quantitative components was under taken at one University in EThekwini District in South Africa. Final year health science students specifically medical (228), occupational therapy (12) and sport science (52) students from the 2009 class were invited to partici pate. Registration lists obtained from each Faculty office allowed exclusion of students' nonresident (South Africa or EThekwini district) or transferring from physiotherapy to any of the chosen professions, to eliminate exposure to physiotherapy as a contaminator. The four page questionnaire with open and closed ended questions (appendix 1) based on the literature (Tsuda et al 1982, Lee andSheppard 1998, Webster et al 2008) consisted of three sections namely biographical details, attitudes and per ceptions and knowledge. Content and construct validity and internal consis tency of the questionnaire were checked using a pilot study. Third year occu pational therapy students and physio therapy lecturers participated in the pilot study. No changes were required as a result of the pilot study and the researchers were assured that the ques tionnaire would achieve the objectives of the study.
All participants signed fully informed consent forms after permission to con duct the study was obtained. The Faculty of Health Sciences Ethics Committee approved the study. Due to the clinical placements of the medical and occu pational therapy students during data collection, questionnaires with complete instructions and information sheet, were handed to clinical group student repre sentatives to hand to medical and occu pational therapy students. Questionnaires were administered to sport science students by the researchers. The question naires were collected by the researchers after a week. An email follow up was undertaken to increase the response rate by medical students.
The data from the questionnaires were reduced to percentages and descriptions by theme. The adequate knowledge scores were derived by quantifying responses obtained on work environ ment, medical fields, referrals received, conditions treated and treatment moda lities used by physiotherapists. The attitude score was calculated by obtain ing a percentage of actual response to overall past physiotherapy exposure, if the participant would recommend physiotherapy, the rating of the physio therapist's role in South Africa and the rating of physiotherapy as a career. If the knowledge and attitude scores were > 50%, they were regarded as adequate and positive respectively. The quantita tive data were subjected to Chi Square tests and Spearman's Product moment correlations at a probability of p<0, 05 using SPSS version 17. The propor tion of participants who responded was worked out as a percentage by health science category.

RESultS
Of the 292 students approached to participate in the study, only 51.0% (n=149) responded even after follow up. However only 83, 2% (124) of the returned questionnaires were eligible for analysis. The analysed question naires included 120 in hardcopy and 4 by email. The participants included 71 medical students (57, 3%), eight occupational therapy (6, 5%) and 45 sport science students (36, 3%). Only 31.1% of the 228 medical students, 66.7 % of the 12 occupational therapy students and 86.5% of the 52 sport science students returned their ques tionnaires. Twentyfive respondents (8.6%) were excluded, of which seven (2.4%) were not SouthAfrican citi zens, one (0.3%) was a dual citizen and seventeen (5.8%) did not reside in EThekweni district.
The demographic characteristics of the participants are shown in Table 1. The majority of medical and occupa tional therapy students were females, while sport science students were mostly male. The majority of the students were between 1824 years of age. Most of the medical students were African (55%), occupational therapy students were White (38%) and sport science students were Indians (31%). The race grouped classified as "other" consisted of Coloured students.
All respondents heard about physio therapy but only 58, 9% was actually exposed to it through direct treatment by a physiotherapist or a family member or friend being treated.
The majority of respondents ( Figure 1) obtained their information about physio therapy from a family member or rela tive, a friend or books. The University career day and newspaper were not sig nificant in creating awareness about the profession.
The majority of respondents have adequate knowledge (knowledge score > 50%) of physiotherapy ( Figure 2). Occupational therapy students were significantly (p<0, 01) more knowledge able compared to the sport science and medical students.
When respondents were asked about where they thought physiotherapists work, Figure 3 shows that the most   Table 2 shows responses with regard to medical fields in which physio therapists work. The majority of respondents regardless of occupa tional group identified orthopedics and sports medicine. None of the occupa tional therapy respondents thought that phy siotherapists work with patients presenting with respiratory disease or thoracic surgery. Fewer medical and sport science students identified obste trics and gynecology.
More than 80% of the medical stu dents knew that physiotherapists could receive referrals from biokineticists, chiropractors and medical doctors but not from nursing staff. Only 50% of the occupational therapy students knew that physiotherapists received referrals from doctors while only 29% of the sport science students had a similar feeling. About three quarters of medical student respondents and half of occupational therapists knew that patients could self refer to physiotherapists.
As far as conditions treated by physio therapists, as shown in Table 3, all occupational therapy students were aware that physiotherapists managed a range of conditions compared to medi cal students and sport science students. Muscle strain, stroke arthritis and para/ quadriplegia were commonly identified.
For treatment modalities used by physi otherapists (Table 4), 100% of occupational therapy and sport science students and 90% of medical students chose massage. Other techniques that were popular included manipulation/ mobilization of joints, pre/post opera tive exercises and cryotherapy. Less than 40% of medical and sport science students chose electrotherapy.
Perceptions and attitudes were deter mined based on whether the respondents were exposed or not to physiotherapy in the past (Table 5). Forty nine percent of medical students had past exposure compared to 75 and 71% of occupa tional therapy and sport science students respectively. This exposure was through themselves, friends or family requiring physiotherapy services.
Past exposure to physiotherapy was significantly correlated p<0, 05) with a positive attitude to physiotherapy in all three groups of respondents. More occupational therapy students who were not exposed to physiotherapy displayed positive attitudes to physio therapy compared to their colleagues who had exposure. Sixtyeight and 81% of medical and sport science stu dents reported being positive about the quality of physiotherapy.
More than 80% of all students would recommend physiotherapy where   required. When asked about their feel ings towards physiotherapy as a career, 66%, 83% and 69% respectively of medical, occupational therapy and sport science students had a positive attitude. The majority of the students, 69% medi cal, 83% occupational therapy and 91% sport science students perceived that physiotherapists plays an important role in health care in South Africa.
Although several comments were made, the comments that are signifi cant to promote planning interventions to improve the image of the profession are presented below. In the general comments section in which only 21% of the respondents stated their views about physiotherapy, 8% was positive and 4, 8% negative. Some of the views are quoted below. Occupational therapy students did not comment. Sport Science students: "Physiotherapists play an important role in our sporting industry" "I think that Physiotherapy is an important asset to the public which is highly under rated similar to Biokine tics and needs to be embraced more by members of the public" Medical students "I realize now that I don't know much about the profession of which I will work so closely within a few years to come.
Please, let us know more about your profession, what exactly you do and how can anyone apply to do the same thing" "I am actually embarrassed by how much I know about Physiotherapy as a rehabilitation practitioner" "I find it confusing trying to figure out where physiotherapists fit into the management of most patients" "Waste of resources" "Physiotherapy is an unnecessary career; it's a waste of patient's money…. Sorry but this is true".
"In my experience bed ridden patients do not receive physiotherapy."

DISCuSSION
This study shows an overall adequate knowledge and positive attitudes towards physiotherapy by selected health science students in EThekwini. The over all response rate was accept able. The poor response by medical students requires further investigation. Some perceptions about physiotherapy were distorted.
Almost ten years ago Lee and Sheppard (1998) suggested that interdisciplinary interaction within the health care team is becoming more recognized as a more effective method of delivering health care. This can only be achieved by team members recognizing and respecting the others professional abilities and techni cal skills (Whyte and Blackburn 1991, Curran et al 2008). The poor response by final year medical students in this study may reveal an unawareness of the value of interdisciplinary interaction and of physiotherapists in particular. This is reinforced by some of the com ments made by some respondents such as "physiotherapy is an unnecessary career". Levine and Kliebhan (1981) believe that with specific reference to physically handicapped children, no discipline has all the desired diagnostic and treat ment services. Our findings of adequate knowledge and positive attitudes by the majority of participants support this. Despite the majority of medical student respondents reporting adequate knowl edge and positive attitudes, it must be borne in mind that only 31% of the medical students participated in this study. It therefore makes sense that patients have shown dissatisfaction with their general medical practitioner's lack of knowledge of physiotherapy and availability of alternative treatments (Harris 1992). Almost 30 years ago, Silva et al (1981) reported that phy sicians felt that if physiotherapists succeed through education, research and practice, they may be able to work truly   (1999) com ments made by respondents in this study suggest that they may have been exposed to physiotherapy but do not understand the specific details of it. Tsuda et al (1982) showed this in their study on high school learners. Although Webster et al (2008) point out that the public and service users are not knowl edgeable about physiotherapy, studies like that by Ogiwara and Nozoe (2005) and efforts by professional organiza tions like the South African Society of physiotherapy show that information is being chan neled to the public. From the current study, it is clear that in addition to information, the consumer requires actual hand on experience of what physio therapy entails (Figure 1).
Similar to our findings Lee and Sheppard (1998) reported that physio therapists enjoyed a positive reputation amongst Southern Australia medical students. Even Lee and Sheppard (1998) found gaps in the medical students' knowledge regarding conditions treat able by physiotherapists even though their general knowledge was good.
Sources from which individuals obtain their information may influ ence their knowledge and their percep tions and thereby alter their attitudes to Physiotherapy. In this study although significantly more students had posi tive attitudes to physiotherapy, more occupational therapy students displayed ambivalent views about the quality of physiotherapy that they were exposed to. Ogiwara and Nozoe (2005) reported that their cohort of study participants failed to identify any sources of information regarding physiotherapy. The current study showed that "word of mouth" through friends and family; direct per sonal or other exposure and books were the major sources of information. It is interesting to note that few respondents used the University career day or news papers. In the 19 sources reported by Kallus et al (1999) personal contacts, mass media and career information were significant. Although Kallus et al (1999) reported the media and family members as common sources of information these sources may portray inaccurate infor mation leading to misconceptions. From the comments by medical students in this study, it seems that they received no exposure to physiotherapy, despite the fact that physiotherapy students obtain clinical training alongside medical stu dents in selected teaching hospitals. The physiotherapy department offers lectures to second year medical students and physiotherapy is an academic discipline within the same University. Ewan (1987) reported that the lack of opportunities for medicals students to work with allied health care professionals in the clinical setting has contributed to their lack of appreciation of the skills of these profes sionals. Lee and Sheppard (1998) stated that 44% of their participants indicated that they did not know enough about physiotherapy to comment in detail on it. Stanton et al (1985) showed that despite physicians' lack of knowledge about physiotherapy they still referred patients to physiotherapy.
In the current study, medical students were happy to refer patients for physio therapy even though they were not totally knowledgeable about services rendered. In the past, physiotherapists were dependent on doctors for patient referral. Webster et al (2008) reported that doctor respondents in their study referred less than 30 percent of patients for Physiotherapy. Doctors must be well informed about physiotherapy (Lee and Sheppard 1998) for them to make appropriate referrals. Since word of mouth referrals are only second to doctors' referrals to physiotherapy (Sheppard 1994), perception of physio therapists seems critical in improving referral rates.
Sixty percent of the respondents in the current study knew that patients can selfrefer to physiotherapists. Webster et al (2008) found that 88% of their respon dents in the United Kingdom were sup portive of being able to refer themselves to Physiotherapy. The responsibility of selfreferral can only come when stake holders have an adequate knowledge, attitude and perception of physiotherapy so that they can make an informed deci sion (Webster et al 2008).
Perceptions about quality of services can impact on patients seeking physio therapy (Potter et al 2003). Stanton et al (1985) believe that physiotherapists are responsible for creating aware ness about their profession. Lee and Sheppard (1998) found that only 68% of college students were aware that Physiotherapists are first contact practi tioners. Sheppard (1994) suggested that educating the public about physiother apy could increase client numbers. In the current study, occupational therapy students who were exposed to physio therapy actually reported less positive attitudes towards it.
Majority of respondents in the current study knew that Physiotherapists work in private practice. Sheppard (1994) found that the physiotherapists most readily distinguished are the ones in private practice.
The present study showed that the majority of respondents knew that phy siotherapists managed musculoskeletal injuries. Sheppard (1994) reported that patients believed that physiotherapists were specialists in muscular treat ment especially pain relief, sport injury management, and back care. Holdsworth et al (2008) reported that general prac titioners in their study recognized physio therapists as complement prac titioners for the management of mus culoskeletal conditions. Similar to this study, Lee and Sheppard's (1998) par ticipants also identified musculoskeletal disorders and strokes as conditions treat able by physiotherapists. Holdsworth et al (2008) found that general medical practitioners recognize physiotherapists as complement practitioners for the management of musculoskeletal con ditions.
Prati et al (2006), similar to the current study, found that certain modalities are typically associated with physiotherapy namely physical exercise, and mas sage versus electrical treatments. The respondents were generally not aware that physiotherapists also managed antenatal care and womens' conditions similar to that reported by Sheppard (1994). Respondents indicated a lack of awareness of physiotherapy and a need for more vigorous marketing (Webster et al 2008).
All respondents in the current study had heard about physiotherapy compared to the 92% percent of respondents in the Ogiwara and Nozoe (2005) study who stated that the first time that they had heard about physiotherapy was in the survey that they undertook. The respondents in that study were high school learners. Kallus et al (1999) said that the public may be exposed to and be aware of the profession of physiotherapy but may not necessarily understand the details about it. Relevant activities have been undertaken by physiotherapists to convey information to the public includ ing school children (Ogiwara and Nozoe 2005;SASP 2009). The identification of specific areas in which gaps are, will allow for specific marketing strategies in these areas. College students interested in studying physiotherapy in Arkansas were not aware of the doctoral degree in physical therapy (Prati et al 2006).
Respondents in this study failed to identify areas in which physiotherapists work similar to the findings by Whitfield et al (1996) who believe that physio therapy does not have a clear identity with the result that the public and health care professionals are unable to differen tiate physiotherapy from related profes sions. Lee and Sheppard (1998) reported that their sixth year medical student respondents found that physiothera pists were progressive, professional and competent with an important role in teaching the public selfresponsibility in health care.
The favourable attitudes and sup portive perceptions of participants in the current study are supported by Silva et al (1981) who found that physicians thought that physiotherapists were highly professional and possess all five of Moore's criteria of professionalism namely motivation and lifelong commit ment to their career, established organi zation, prolonged period of specialized education and training, orientation towards serving clients through compe tent application of specialized knowledge and skills and autonomy of judgment within the profession. LunaMassey and Smyle (1982) found that consumers felt that physiotherapists were not as effec tive in evaluative skills as the physician. This aspect was not considered in the current study.
Several questions arise from the find ings of this study and the available lite rature on the topic. Although respondents in the studies are adequately knowl edgeable and have supportive attitudes and perceptions about the profession and its practitioners, the status of the profession has not changed. Marketing and awareness strategies should target a wide range of the population. The current study showed that the majo rity of the respondents had exposure to physio therapy either personally, through their family or friends. Physiotherapy associations around the world are now promoting voluntary service to commu nities. An audit is required to evaluate the extent of involvement, response rate to surveys and knowledge, perceptions and attitudes.

CONCluSION
Final year students from selected health care professions have adequate knowledge and positive attitudes and perceptions towards physiotherapy. Of concern is the 50% of non respondents.
Physiotherapists may need to offer more voluntary services to communities in an effort to educate and create aware ness. The study was limited by the poor response of medical students. Time and funding constraints limited the popula tion for this study. The generalizability of the findings is confined to the popula tion under study.