Perceptions of practising physiotherapists in Saudi Arabia about their role in the health promotion of patients with musculoskeletal conditions: a qualitative study

Abstract

Objective:

This study aimed to explore physiotherapists’ perceptions in Saudi Arabia about their understanding and role in health promotion through lifestyle behaviours and risk factors assessment and management of patients with musculoskeletal pain and disabilities.

Study design:

Qualitative study.

Method:

One-to-one interviews with 12 physiotherapists (six females; mean age 34.5 ± 8) within a constructivist framework. Interviews were recorded, transcribed verbatim, and analysed using a thematic analysis approach.

Result:

Three themes were identified: (1) the physiotherapists’ awareness and knowledge of health promotion; (2) current practice of physiotherapists to implementing health promotion practice; and (3) the physiotherapists’ perceived barriers to implementing health promotion practice. Participants generally perceived health promotion to be within their scope of practice. However, their understanding and approaches to deliver this practice were varied and non-standardised. Some barriers to routine engagement in health promotion were identified, including time constraints, the beliefs of healthcare practitioners, and limited education and training.

Conclusion:

This study highlighted that physiotherapists acknowledged the role of health promotion in their practice. However, there were different explanations of the concept and it was informally practised.

Keywords

health promotion physiotherapy musculoskeletal

Introduction

Chronic lifestyle-related diseases and non-communicable diseases (NCD) are now important global causes of morbidity and mortality (1). Because they are strongly related to modern lifestyle behaviours, these diseases, including heart disease, stroke, cancer and diabetes, are mostly preventable or, at least, controllable. Lifestyle behaviours are also linked to chronic musculoskeletal (MSK) pain and disability, which together affect millions of people worldwide and cost billions of dollars annually in healthcare, disability and loss of productivity (2,3).

While many lifestyle behaviours can influence an individual’s overall health and fitness levels, the main lifestyle determinants of chronic diseases are inactivity, poor diet, obesity, smoking, lack of quality sleep, and stress (4). Compelling evidence supports the need to urgently address these negative behaviours, especially for controlling chronic MSK pain, morbidity and disability (5). For example, physical activity and exercise interventions are associated with a higher quality of life and improved health (6,7). Studies have also focused on reducing prolonged inactivity because of the detrimental changes associated with a sedentary lifestyle (8,9). Obesity and nutrition also impact MSK pain and the quality of life, and people with chronic pain tend to have poor eating habits (10 –12).

Smoking is a significant distractor from pain, but it increases the risk of widespread MSK pain (13 –16). Therefore, orienting patients with chronic pain about the harmful effects of smoking and providing alternative distractors might be a successful intervention for MSK pain (17). Disturbed sleep is another lifestyle factor commonly prevalent in patients with chronic pain (18). The association could be reciprocal, in that pain could interrupt sleep, and poor sleep can aggravate or worsen the pain (18). Furthermore, a number of patients with low back pain complain of insomnia (19). Additionally, stress and specific psychological factors are highly associated with chronic pain and are significant predictors of the transition from acute to chronic pain (20,21).

Assessing and modifying lifestyle behaviours has been a well-established approach to managing many NCDs such as chronic heart and lung disease and diabetes. Physiotherapists (PTs) encounter many patients with chronic MSK disabilities and other comorbidities who have unhealthy lifestyles that need to be addressed. Health promotion may encompass a wide range of interventions, including improving health literacy about lifestyle behaviours to enable people to play an active role to improve their health and prevent chronic conditions (22). Multiple reviews have suggested that health promotion in this regard is within the scope of PTs; they can contribute effectively to promoting health when managing MSK conditions (5,22,23).

However, little is known about the current practice for addressing modifiable lifestyle behaviours in physiotherapy and PTs’ perception of barriers to implementing health promotion in their practice. Therefore, this qualitative study aims to explore the perceptions about health promotion for patients with MSK disorders among PTs practising in Saudi Arabia.

Methods

For this qualitative study, one-to-one semi-structured interviews were conducted with 12 PTs, and they were asked about their perceptions of their role in the health promotion of patients with MSK conditions, including their approaches toward lifestyle behaviours assessment and management.

Participants

Participants were recruited from multiple tertiary and secondary care centres in Riyadh, Saudi Arabia. Purposive sampling was employed, to allow for maximum variation in education, experience and gender within the sample. PTs were categorised into three levels based on their years of experience: 0–4, 4–10, and more than 10 years. Participants’ education levels were also recorded: entry-level Bachelor’s degree, Master’s degree or diploma, and PhD. Initially, 18 candidates were approached by phone by one of the researchers (FA). Of these, 12 responded and consented to participate in the interview.

Interviews

A topic guide was developed based on the findings of two previous studies (24,25). A qualified male researcher (FA), who holds a PhD in physiotherapy and has more than seven years’ experience, was responsible for conducting the interviews. Each interview was conducted on work days in a conference room within the PT department of the care centres and lasted 25–45 minutes.

Although English is the primary communication language within the Saudi healthcare system, we conducted our interviews in Arabic language (native language) to gather in-depth information and understand the cultural context of the setting. In line with earlier literature (5,22), we defined health promotion as the process of improving health literacy about lifestyle behaviours. This guided the interviews among the participants, whenever they deviated from the topic.

Ethical consideration

Ethical approval was obtained from King Fahad Medical City (IRB: H-01-R-R-012), and the study was conducted in November 2016. All interviews were digitally recorded and then transcribed verbatim by FA. All data files were stored in a secure folder in a university computer system. All of the interviewees were assured their identity would be kept confidential, and they provided consent before starting the interviews.

Data analysis

This study used a framework thematic analysis (26,27). Each transcript was analysed by two researchers (AA and MA). Both researchers met regularly to discuss the interpretation of the data. (MA) developed the framework of coding. Then (AA) independently coded 30% of the transcribed data before they met to compare codes. This process allowed the coding framework to evolve. Afterwards, codes were tabulated under a commonly identified theme. Additionally, (MA) scheduled a periodic meeting for the entire research team to discuss the interpretation of the data. Finally, excerpts were translated into English by an external linguistics specialist, then the translated version was checked by all the research team members to ensure accuracy of meaning.

Results

One-to-one interviews were conducted with 12 PTs (6 females and 6 males). The mean age of the participants was 34.5 years, and the mean years of experience was 9.4 years. Half of the participants practised in a tertiary healthcare setting, while the other half practised in a secondary care setting. At the time of the study, physiotherapy services in Saudi Arabia were not being provided in primary care settings. Table 1 shows the characteristics of participants.

Table 1.

Characteristics of physical therapist participants.

Participant code	Age (years)	Gender	Education	Experience (years)
PT 1	27	M	Bachelor’s degree	2
PT 2	27	M	Bachelor’s degree	3.5
PT 3	53	M	Bachelor’s degree	26
PT 4	40	M	Master’s degree	12
PT 5	31	F	Bachelor’s degree	5
PT 6	40	F	Postgraduate diploma	16
PT 7	32	M	Master’s degree	9
PT 8	39	F	Master’s degree	17
PT 9	27	M	Bachelor’s degree	4
PT 10	31	F	Postgraduate diploma	10
PT 11	27	F	Bachelor’s degree	3
PT 12	37	F	Bachelor’s degree	6

Three main themes were identified from the interview data about the role of a PT in health promotion among people with MSK conditions: (1) the PT’s awareness and knowledge of health promotion; (2) the PT’s current practices related to health promotion; and (3) the PT’s perceived barriers to implementing health promotion practice.

First theme: Awareness and knowledge of health promotion

Many interviewees agreed on the importance of incorporating health promotion into the physiotherapy practice.

Certainly, important because it will help improve patients’ lives, so it’s definitely something important. (PT 1)

Talking about the lifestyle and how it is very important to be considered when we treat patients or assess patients with musculoskeletal injuries. (PT 6)

The understanding of the concept of health promotion was not consistent across participants. Nonetheless, some agreed that health promotion is linked to the quality of life.

Health promotion! When I hear about this term, I immediately think about how to improve the quality of life. (PT 3)

On the other hand, a small number (n = 2) of participants explained health promotion from the perspective of raising awareness about multiple healthy lifestyle aspects.

It’s all about increasing awareness about all the aspects that are related to health, including lifestyle, eating habits, relations, how I am taking care of my medical status, how I’m dealing with myself if I feel stressed. (PT 6)

However, the majority of participants had a narrow understanding of lifestyle as it relates to physiotherapy; some viewed it as physical postures:

It’s all about the postures that patients use in their daily life. (PT 9)

Additionally, many participants highlighted the importance of physical abilities in the context of health promotion. For example, PT 3 stated that ‘being physically active could prevent diseases and maintain physical strength, which promotes well-being’ when asked about the meaning of health promotion.

Most of the participants (n = 11) agreed that instructions and patient education is how health promotion is achieved:

Healthcare promotion depends mainly on the education given to the patient and helps to improve quality of life, especially if the education is evidence-based. (PT 2)

It is more educational than a practical thing. It is essential awareness and education. (PT 9)

Second theme: Current practices related to health promotion

Participants highlighted several roles that PTs play, including the promotion of proper nutrition, encouraging an active lifestyle, and raising awareness about mental health:

I instruct my overweight patients to reduce their weight. It’s about changing your habits of food. Like don’t eat fried food, don’t eat sugar, try to reduce the sugar, cut the sugar if you can. (PT 5)

However, one participant said that their role was limited to raising patients’ postural awareness and telling them about proper lifting and handling:

We mainly provide advice about posture and the best way to sit without harming the body. (PT 1)

The PTs highlighted their lack of knowledge and confidence about how to formally assess lifestyle risk factors, which made them unwilling to use any standardised tools:

Not very confident; because I cannot measure it, I cannot assess, I cannot compare. (PT 5)

The majority of the PTs thought that assessment should be based on the patient’s medical history:

Assessment of lifestyle risk factors is usually carried out by taking the medical history of the patient. (PT 1)

Third theme: Perceived barriers to implementing health promotion practice

The limited amount of education and training that PTs receive at the undergraduate level was a key factor that influenced their understanding of their role in health promotion. Participants were in general agreement about the lack of education and training on health promotion for people with MSK disabilities:

At the university level, we have only a very basic understanding of the concept. Most of our understanding is gained after graduation, in practice. (PT 3)

Knowledge and training are the main reasons why the physiotherapist does not assess or treat risk factors for lifestyle behaviours. (PT 1)

Some PTs also highlighted the lack of time as a barrier to promoting health:

When you have multiple patients waiting, for sure you will not provide any assessment or advice for risk factors. (PT 3)

Moreover, some PTs perceived that patients’ beliefs and attitudes could be barriers and may hinder health promotion. In particular, they were concerned that patients may feel that providing education and instructions on a healthy lifestyle are not within the scope of PTs’ practice:

If you give the patient education or instruction, most will say this is not an intervention! So, patient belief about our role might be a barrier for physiotherapist intervention. (PT 5)

Discussion

This study aimed to explore how PTs practising in Saudi Arabia perceive their role in the health promotion of patients with MSK conditions and the barriers they perceive in assessing and managing lifestyle-related behaviours. The results of this qualitative study identified three conceptual and practical themes.

The first theme is related to PTs’ awareness and knowledge of the concept of health promotion as related to the assessment and management of lifestyle behaviours and risk factors. Participants in the study generally agreed that health promotion should be practised within physiotherapy. This is consistent with the finding in previous studies from different countries (28 –31) that health promotion is part of the PT’s practice. However, some participants in this study had a narrow view of health promotion; they were focused on ergonomic concepts, such as proper lifting and postural correction. This might be due to an inadequate understanding of health promotion within the context of assessment and management of lifestyle behaviours (28 –31). Despite a close relationship between ergonomic as well as other physical factors and the profession of physiotherapy, these factors represent just one aspect of the broad concept of health promotion (22). Reducing the PT’s role to only the physical aspects may reflect a limited understanding of the scope of physiotherapy. Such a limited grasp of the concept of health promotion may be linked mainly to PTs’ education.

Furthermore, participants reported that their knowledge about health promotion was mostly acquired after graduation and that undergraduate education did not cover these topics. It should be noted that content on health promotion is not covered in entry-level physiotherapy teaching courses in some countries, and this was also highlighted in a study on undergraduate physiotherapy training programmes in South Africa (32). Similarly, a qualitative study in acute settings found that more experienced PTs have better knowledge about health promotion (31). Thus, it would be worthwhile to examine the public health content in physiotherapy undergraduate programmes offered globally in order to align the contemporary practices on health promotion (33).

The second theme of this research explores how PTs currently promote health. While some participants showed a biopsychosocial approach to health promotion, others adopted a biomedical approach, limiting the idea of health promotion to only lifting and posture correction. By using the biopsychosocial approach, a PT will be able to uncover the psychological and social components of a patient’s experiences (34). Such an approach also considers the patient’s values and beliefs, as well as the intrinsic and extrinsic resources available to the patient (35). It requires the therapist to lose some control over the biological ideology in order to invite the patient’s inputs to provide ideas on how to pursue the treatment plan.

To ensure that the translation of population-based health messaging promotes rather than diminishes an individual’s well-being, PTs must conduct health promotion interventions with a critical and reflective mindset (34,36). Health professionals who want to incorporate population-based health promotion strategies into their disciplinary practice should be prepared to critically examine and expose the frequently hidden values and assumptions that underpin definitions of health and population-based health promotion strategies. For example, a qualitative study on PTs’ attitudes towards obese patients, involving 265 PTs, found that PTs tended to stigmatise clients by offering only rudimentary information and failed to elicit information about their beliefs, comprehension and personal context (37).

The third theme of this study addresses potential barriers to implementing health promotion in the current physiotherapy practice. Confidence, knowledge, and the amount of time needed to assess and manage lifestyle behaviours were consistently identified as the main obstacles. Although the PT can play a direct role in health promotion through nonpharmacological interventions, including education, this has not been formally recognised as a required competency in many physiotherapy programmes (30). Training therapists in health promotion may have an impact on their confidence and usage of these skills. In addition, raising awareness about the importance of health promotion and wellness to general health may help PTs rearrange their priorities and find more time to promote health among their patients.

Some of the interviewed PTs felt hesitant about promoting health because they believed that the patients had certain expectations about physiotherapy interventions. A previous study (31) reported the same issue in physiotherapy practice in the UK. One of the interesting findings of this study is that PTs think that patients’ beliefs about the role of the PT role might be a hindrance. However, Black et al. (38) explored patients’ beliefs about a PT’s role in health promotion and reported that the majority of participants thought it was appropriate for physical therapists to talk to them about and be role models for the health behaviours, especially in terms of physical activity, weight control and non-smoking. Moreover, involving the patient in setting a reasonable goal was identified by Schoeb et al. (39) as a complex interaction that should not be treated as a predetermined process.

Although participants in this study agreed that health promotion was a part of their role, they reported a lack of confidence and knowledge in assessing some of the health-related lifestyle behaviours. No government policy in Saudi Arabia limits the practice of health promotion to a specific profession. Additionally, the interaction between lifestyle behaviours and various MSK conditions suggests that PTs are in an excellent place to enhance their treatment outcomes by promoting health. However, adequate education and support may improve PTs’ confidence and self-efficacy in assessing and managing health-related lifestyle behaviours (40). Developing pathways to promote health on an organisational level may also improve PTs’ practice in this regard (41).

These findings highlight how PT education and training should provide opportunities to acquire knowledge and skills related to health promotion, thus ensuring effectively integrating health promotion into clinical practice. PTs should also pursue continuing education programmes to enhance their knowledge and skills related to health promotion. The entry-level PT curriculum should be reviewed and updated to incorporate contemporary modules specific to health promotion. Most of the PTs in this study agreed on the importance of incorporating health promotion into the physiotherapy practice, and they felt that they are in an ideal position to promote health and wellness among their patients and clients. However, patients and clients often fail to recognise the role of the PT in promoting health. To change this, we should take a more active role in educating patients and clients about the PT’s role.

It should be noted that our result might lack generalisability in other countries with different PT training and health systems. Therefore, similar studies need to be conducted in different countries. Additionally, large observational studies are needed to assess the degree to which results from a large PT sample agree with the findings of this study.

Limitations

This is the first study to explore this topic in the Middle East, but we note some limitations. The study participants being polled from one country of origin and the nature of qualitative research limit the generalisability of the findings. However, it should be noted that the participants had different backgrounds and received their undergraduate degrees from various universities. The other limitation is the interviewer bias. Given that the interviewer was a PT, it may have influenced the interviewees’ response. However, the interviewer closely followed the topic guide and did not know the research participants previously. Additionally, our interviews were guided by our definition of health promotion as ‘the process of improving health literacy about lifestyle behaviours’. This may not correspond with the WHO definition of health promotion as ‘the process of enabling people to increase control over, and to improve their health’ (42). However, Bandura has described how quality of health is heavily influenced by lifestyle habits (43). Therefore, enabling people to stay healthy by exercising more, reducing dietary fat, avoiding smoking and managing stress is part of health promotion practice (43).

Conclusion

While health promotion lies within the current global scope of physiotherapy practice, it is being viewed in a variable and non-standardised way by PTs in Saudi Arabia. The main perceived barriers to adopting this practice were limited knowledge and training, lack of confidence, and time constraints. The findings reported here are essential for designing a larger observational study to explore the concept of health promotion among many practising PTs in Saudi Arabia.

Footnotes

Acknowledgements

We are also immensely grateful to all participants in this study.

Authors’ contributions

All authors have contributed equally in writing the study protocol and obtaining ethical approval. FA and MH were involved in the data collection. AH and MA were involved in the data analysis and interpretation. All authors read and approved the final manuscript.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by King Abdulaziz City for Science and Technology, Saudi Arabia (Grant research number 05-18-03-001-0001).

Ethical approval

Ethical approval was obtained from King Fahad Medical City, Riyadh, Saudi Arabia (IRB: H-01-R-R-012)

ORCID iDs

Faris A. Alodaibi

Ahmed. S. Alhowimel

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