Knowledge and Attitudes of Rehabilitation Professional Toward Telerehabilitation in Saudi Arabia: A Cross-Sectional Survey

Introduction

Several challenges have delayed the effective implementation of telehealth practices in Saudi Arabia, despite its emerging trend in the past decade. ¹ Countries such as Pakistan, Australia, and the United States, with high percentages of people living in rural areas where access to medical care is limited, are facing similar challenges. ^{2 –4}

Telemedicine is an umbrella term, but it is specifically used to describe long-distance medical services provided by medical practitioners, instead of the traditional face-to-face mode of treatment. Telerehabilitation services are provided by rehabilitation practitioners, such as physiatrists, speech therapists, occupational therapists, and physical therapists. ²

Telerehabilitation uses simple technologies such as mobile phones and video conferencing, which enable therapists to follow up with their patients while they perform rehabilitation exercises and tasks at their own homes, that is, their most natural environment. ^2,5 Today, information communication technologies (ICTs) such as computers and mobile phones are accessible to most people. ⁶ In Saudi Arabia, there are 41.31 million mobile subscriptions, and 89.5% of them have mobile broadband services. ⁷ There is evidence that telerehabilitation is as effective as face-to-face care and that it also improves the quality of life of rehabilitation patients. ^3,8

It facilitates continuity of services throughout the rehabilitation process, including consultation, assessment, intervention, and counseling. Furthermore, it has been identified as an effective tool to improve clinical outcomes and quality of life by facilitating early supported discharge. ⁹

Telerehabilitation is a well-known practice in the medical field worldwide but not locally. In 2011, the Saudi Arabian Ministry of Health launched a telemedicine project, the Saudi Telemedicine Network (STN), covering all types of health care facilities, including private, military, and Ministry of Health facilities. ⁶ The STN was developed to build a foundation for telemedicine in Saudi Arabia, in cooperation with Canada Health Infoway and the Ontario Telemedicine Network. According to the 2016 Saudi General Authority of Statistics, there are 667,280 people living with disabilities in Saudi Arabia (comprising 3.3% of the citizens surveyed), including people living with communication, cognitive, mobility, hearing, and self-care disabilities. ¹⁰

Establishing and implementing ICT in an organization or country comes with unique barriers and challenges that might not resemble those encountered previously by others. These challenges are related to the organization or country's context and environment (e.g., macroeconomic, cultural, structural, social, and political situations), potential users (e.g., the level of acceptance of and attitude toward ICT), strategy and plan (e.g., standards and processes for ICT), and ICT innovation needs (e.g., equipment, infrastructure, speed, and user-friendliness). ¹

Studies have found that the attitude of potential users of a new technology can be made positive when that technology is supported by direct users. ^11,12 A lack of acceptance among clinicians is considered to be a reason for the poor uptake and sustainability of telehealth. ¹ Engaging service providers from the initial implementation stages of a telehealth project can have a direct positive impact on the integration of telerehabilitation services into practice.

This study aimed to explore Saudi-based professionals' knowledge of telerehabilitation and their confidence in using this emerging service with their patients. This study is the first of its kind in Saudi Arabia and in the Middle East, specifically in regard to exploring clinicians' perspectives.

Materials and Methods

Participants were included using nonprobability sampling method. E-mails were sent to administrators of various rehabilitation facilities across different regions of Saudi Arabia, which included the link for online survey. The administrators were requested to forward the e-mail to respective rehabilitation departments and employees. Data regarding actual number of clinicians who received the e-mail were not collected, hence response rate and details of nonresponders could not be included. Participants included physiatrists, orthotists/prosthetists, physical therapists, occupational therapists, psychologists, speech language pathologists, and rehabilitation nurses. The demographics of participants are shown in Table 1. The survey included 82 rehabilitation professionals: the majority (51.22%) came from the middle region, 29.27% from the western region, 12.20% from the eastern region, 3.66% from the southern regions, and 3.66% from the northern regions of Saudi Arabia. Sixty-five (79.2%) respondents worked in a facility that offered inpatient rehabilitation services.

Survey questions were adapted from those used in a previously published study about telerehabilitation; modifications were made to focus on Saudi Arabia. ⁴ It was pilot-tested by four rehabilitation professionals, and afterward minor edits were made. The survey included 14 close-ended questions targeting five domains: demographics, telemedicine knowledge, telerehabilitation service knowledge, social acceptance of these services, and risks associated with these services (Table 2). We decided to terminate survey collection after 6 months. The survey type was multiple choice questionnaire.

Survey results were analyzed using Microsoft Excel, and then descriptive statistics were obtained.

Results

Participants reported similar results in terms of their knowledge about telemedicine and telerehabilitation. The majority of the participants (46%) were aware of telerehabilitation service technology but had not used it. Approximately 19% of others reported that they were aware of relevant technology and used it on an intermittent basis, 18.29% had good knowledge of it and used it on a regular basis, and 15.85% did not know about the technology.

When asked about their opinions regarding methods to improve rehabilitation service delivery in Saudi Arabia, 69.51% considered both telerehabilitation and community-based rehabilitation as the best service delivery methods. The telerehabilitation and community-based services included consultation, prescription, delivery of complex therapies, monitoring, evaluation, follow-ups, and nursing care.

About 43% of participants reported that lack of ICT knowledge, high cost of ICT, rapidly changing ICT, and patient compliance were the main factors that led to their limited use of telerehabilitation systems. In addition to these limitations, 36.59% of respondents named the attitudes of policy makers, whereas very few participants (6%) thought that lack of skilled personnel and patient compliance factors hinder the use of telerehabilitation services. The majority of the participants (52.44%) considered patient data security, patient privacy, and/or consultation from an unauthorized person to be risks associated with telerehabilitation services in Saudi Arabia.

Discussion

This study revealed that rehabilitation professionals in Saudi Arabia have a general awareness of telerehabilitation service technology, but the majority has not used it. They believe that it can provide various services, including consultation, prescription, delivery of complex therapies (which prevents them from receiving rehabilitation services), and misunderstanding of the role that health facilities play in their lives. In contrast to the accessible rehabilitation services available in metropolitan areas, there are fewer medical practitioners in rural areas, which is itself a barrier to accessing health care in rural areas. ²

Telerehabilitation should be used to support and improve community-based rehabilitation, especially in rural and developing areas where these services are expensive and limited. ⁴ In Saudi Arabia, there are few rehabilitation hospitals, and these are located only in the three major cities of the country (i.e., Riyadh, Jeddah, and Dhahran). Most patients must, therefore, travel for rehabilitation consultations and follow-ups, which results in high costs, limited visits, and inconvenience to patients and their families.

Rehabilitation patients generally require long-term care for their social, physical, cognitive, and emotional deficits. ⁶ These deficits result in patients becoming increasingly dependent on others and decrease their life participation, thus lowering their quality of life. ^6,13 Telerehabilitation is a good alternative for patients who live outside the major cities of Saudi Arabia. Telerehabilitation facilitates the provision of immediate feedback that is customized to the patient's needs and directly addresses their functional challenges while monitoring their functional levels in their own homes. These benefits increase patient compliance. ^1,4 Continuous staff training significantly boosts participants' confidence in using telerehabilitation services for assessments and intervention. Cottrell et al. studied telerehabilitation providers' knowledge and experience through a period of 6 months. Their study found that with increased clinical experience, participants became more confident about using telerehabilitation. ³ This supported recent research findings that specific hands-on training facilitates the acceptance of new technology. The knowledge of telerehabilitation services will increase when Saudi rehab professionals are trained to use the relevant technology and are provided continuous support, which will also increase their confidence.

These findings are similar to those of Zahid et al., who maintain that lack of ICT knowledge among practitioners and concerns around patient confidentiality are among the factors limiting the practice of telerehabilitation in Pakistan. ⁴ However, rehabilitation professionals in Saudi Arabia, unlike those in Pakistan, believe that both telerehabilitation services and community-based rehabilitation are the best service delivery methods. A limitation of this study is the small sample size; furthermore, the age range of the participants was not obtained and might offer additional information about their ICT knowledge. The age of the patients receiving telerehabilitation services also has an impact on its effectiveness. ¹⁴

Conclusion

We maintain that there is a strong need to adopt measures to encourage the use of telerehabilitation services. The concerns of clinicians, as outlined earlier, can be addressed by enhancing awareness about telerehabilitation and establishing local telerehabilitation guidelines. This will also align with the Ministry of Health's vision with regard to enabling ICT for people with various disabilities to ease their access to and participation in their communities. Furthermore, this study emphasizes the gradual implementation of telerehabilitation, careful selection of appropriate patients, comprehensive staff training, and the need for policy makers to take initiatives.