ABSTRACT
BACKGROUND: Access to basic health care services through the primary health care (PHC) settings, was affirmed as a fundamental human right by the World health organisation (WHO) in 1978 in Alma Ata (Kazakhstan). Internationally, interdisciplinary collaboration among health care professionals (HCPs) have been the preferred approach to addressing the health and psychosocial needs of the populace. The PHC being the first point of contact for most Nigerians and the cornerstone of health care policies in Nigeria, covers promotive, preventative, curative and rehabilitative services. Although, Physiotherapy has ideally qualified personnel to contribute to the attainment of the goals and objectives of the PHC policies, these services are mostly carried out by other HCP’s subdivided as clinicians (medical doctors, dentists, nurses/midwives, optometrists, pharmacists, radiographers, laboratory scientists) and clinical assistants (pharmacy technicians, radiography technicians, laboratory technicians and community health extension workers). Physiotherapy services are mostly concentrated at tertiary and secondary health care settings.
AIM: To determine the awareness and explore the perceptions of clinicians and clinical assistants employed in the type 3 primary health care (PHC) settings of Rivers East Senatorial district of Rivers State, Nigeria, regarding the roles of Physiotherapy in a PHC setting.
METHODOLOGY: A multiple methods’ approach was utilised in this study, comprising of quantitative (N = 219) and qualitative (N = 17) components. Both quantitative and qualitative components were planned and implemented at the same time to answer research questions. The quantitative component used a self – administered questionnaire (reliability [= .879] and validity established) to collect data from participants on their awareness on the roles of physiotherapy in a PHC setting, while the qualitative component used focus group discussions (FGDs) to explore the perceptions of other health care professionals on the roles of physiotherapy in a PHC setting. The target population for this study was 453 PHC professionals with at least two years working experience in a type 3 PHC settings. Health care professionals in this study included clinicians (doctors, nurses, pharmacists, radiographers, medical laboratory scientists, dentists, optometrists) and clinical assistants (dental technicians, laboratory technicians, radiography technicians, community health extension workers). The comprehensive PHC (type 3) facilities were purposefully chosen for this study based on their wider population coverage, responsibilities to population-based health care and clinical/clinical assistants staff strengths and experience as compared to other health care facilities (type 1 and 2). Participants were recruited from thirty eight type 3 PHC facilities in both rural and urban settings of Rivers East Senatorial district, using a non-probability sampling strategy. Yamane’s formula with the help of a powered calculator was employed to determine the sample size of the quantitative component. At 95% confidence interval and a 5% error margin, at least 216 health care professionals had to participate in this study. A self – administered questionnaire was developed based on existing literature and the roles of the physiotherapist in global health and PHC as outlined by the World Confederation for Physical Therapy (WCPT). Excerpts from these works together with the aims and objectives of this study guided the development of the questionnaire items. The questionnaire consisted of two sections (sections A and B). Section A; addressed the socio-demographic details of participants (age, gender, profession, institution, qualification, working experience in other healthcare settings, including overseas practice experience and years of working experience in the PHC settings). Section B; sought to determine the awareness on the roles of Physiotherapy in a PHC setting (Health promotion, health education, disease/disability prevention, treatment and rehabilitation) by other health care professionals. In order to establish clarity and accuracy, both questionnaire (quantitative) and FGD instrument (qualitative) were piloted with fifteen and five type 3 PHC professionals (clinicians/clinical assistants) respectively, whose criticisms and suggestions were taken into cognizance before the commencement of the study. The reliability of the newly developed instrument was established by performing a test-retest reliability study (= .879). Permission and ethical clearance were obtained from senate higher degrees and biomedical research ethics committee at the University of the Western Cape, South Africa. Further permission was sought and obtained from the Rivers State PHC management board, Rivers State, Nigeria. Permission was also sought and obtained from the directors of health of selected local government areas. Finally, permission was sought and obtained from the administrative heads of selected PHC centres before the commencement of data distribution and collection.
RESULTS: A total of 300 questionnaires were distributed to thirty eight PHC centres, situated within five out of eight local government areas in the Rivers East Senatorial District. Of the 300 questionnaires that were distributed, 236 were returned before the final data collection date that was provided. However, only 219 completed questionnaires met the study inclusion criteria during sorting as health care professionals (clinicians/clinical assistants), and were included in the final data analysis. The 17 (7.2%) questionnaires were excluded from the final analysis as they were not considered clinicians/clinical assistants (e.g. health information officers) in this context. The mean age of the survey (quantitative) participants was 38.5 years (SD = 9.17). The majority (63.5%; n = 139) of participants were females. The majority of participants (38.4%) were in the age range of 31-40 years. Also the majority of the participants had at least six years working experience in the type 3 PHC settings (Mean years of working experience = 10.6 years; SD = 7.53), with 82.2% also having working experience in other health care settings other than the PHC settings. Similarly, a total of 17 health care professionals participated in the focus group discussion (FGDs), with a minimum age of 32 years and maximum age of 56 years old (mean age = 42.8 years; SD = 11.0). Analysis of the quantitative component, was conducted with the help of a computer-based statistical package for the social sciences software, version twenty five (IBM SPSS 25.0). Inferential statistics such as the independent samples t – test was employed to compare mean scores of health professional groups (Clinicians vs Clinical Assistants) on their awareness on the roles of Physiotherapy in a PHC setting. Similarly, the qualitative component was analysed thematically with the aid of atlas.ti software, version 8 (ATLAS.ti 8). The Cronbach alpha for the twenty five (25) items subscales based on the roles of Physiotherapy in a PHC setting were calculated (= .879), by adding the number of scaling items ranging from strongly disagree to strongly agree (1 = strongly disagree, 2 = disagree, 3 = undecided, 4 = agree, 5 = strongly agree), with higher scores indicating participants’ awareness on the roles of Physiotherapy in a PHC setting. The following criteria were used for awareness categories: inadequate ≤ 49% scores, marginal ≥ 50 – 79% scores and adequate for ≥ 80% scores. The reliability for each sub-scale items were as follows: A) Health Promotion (= .663); B) Health Education (= .753); C) Disease/Disability Prevention (= .705); D) Treatment (= .682); and E) Rehabilitation (= .821). An independent samples t-test was conducted to determine if a difference existed between the mean scores of clinicians and clinical assistants with regards to the awareness on the various roles of Physiotherapy in a PHC setting. The results showed that there was no statistically significant (p = 0.409) difference in the mean scores of the clinicians (M = 21.05; SD = 2.14) and clinical assistants (M = 20.40; SD = 2.44) on health promotion, health education, treatment and rehabilitative roles of physiotherapy in a PHC setting. The researcher therefore failed to reject the null hypothesis. The only statistically significant (p = 0.040) difference in the scores between the two groups were detected in their awareness, specifically pertaining to the role of the physiotherapist in the prevention of disease/disability in a PHC setting. Similarly, the thematic analysis of the qualitative data revealed that, though there is general poor awareness on the roles of Physiotherapy in a PHC setting by other health care professionals, most of the participants in the FGD perceived Physiotherapy to be relevant in the PHC settings, especially with regards to interdisciplinary collaboration among healthcare professionals (HCPs).
CONCLUSION: The results of this study revealed a limited awareness on the roles of Physiotherapy in a PHC setting by other HCPs (clinicians and clinical assistants) in type 3 PHC settings. The majority of other HCPs had adequate awareness on the promotive, treatment (curative) and rehabilitative roles of Physiotherapy in a PHC setting, but poor awareness on the educative and preventative roles of Physiotherapy in a PHC setting. It is the perceptions of other HCPs that Physiotherapists have important roles to play in the PHC settings and should be integrated into the PHC team as first contact with the public, especially in the prevention and management of musculoskeletal conditions and patient triage.