ABSTRACT

Background Health-promotion (HP) practice among African physiotherapists has not previously been assessed despite the central role that physiotherapists play in HP. This survey therefore explored HP practice, self-efficacy and outcome expectation (OE) among Nigerian physiotherapists, regarding arthritis and low-back pain (LBP), nutrition and overweight, physical fitness and activity (PF-PA), and heart disease (HD) and stroke.

Method This survey involved 110 physiotherapists from 12 randomly selected tertiary hospitals across Nigeria. Information on demographics, practice characteristics, HP practice, self-efficacy and OE from HP was collected using a pilot-tested questionnaire.

Results The physiotherapists reported that during the last month, half of the cases they had assisted in concerned arthritis and LBP, PF-PA, and HD and stroke. The number of cases concerning nutrition and overweight issues was somewhat lower. However, they only listened to, educated, developed and set goals for, and referred patients to HP in less than half of the cases for all health areas. Significant associations were found between time spent listening to patients, and self-efficacy (r=0.27; p=0.004) and OE (r=0.20; p=0.03) in HD and stroke cases, as well as for self-efficacy and OE in cases concerning nutrition and overweight (r=0.20;p=0.02), PF-PA (r=0.77; p<0.001), arthritis and LBP (r=0.58; p<0.001) and HD and stroke (r=0.71; p<0.001).

Conclusion There are needs to improve self-efficacy and OE regarding HP practice among Nigerian physiotherapists when handling patients with multiple health issues.

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Introduction

Health is a dynamic state of well-being characterized by a physical and mental potential, which satisfies the demands of life commensurate with age, culture, and personal responsibility (1). Health promotion (HP) is the process of enabling individuals and communities to increase their own control over the determinants of health, and thereby improve their health and quality of life (2;3). The physical dimensions of health comprise nutrition and bodyweight, disease and injury, exercise, rest and relaxation, stress, sports and fitness, and recreation, which are areas usually addressed during a
physiotherapy consultation (4). A combination of different approaches to HP programmes is now becoming the norm (5).

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Despite the central role which physiotherapists play in HP, reports on the practice of HP among African physiotherapists are sparse. This is also the case in Nigeria even though guidelines for physiotherapists’ education and practice emphasize HP. This emphasis is in a bid to strengthen physiotherapists’ professional role in prevention, diagnosis, and treatment of physical and functional disabilities for patients and communities (6). Indeed, an important part of physiotherapists’ practice is to help individuals prevent diseases and promote health, wellness and fitness (7), which suggests
that physiotherapists should be involved in primary, secondary, and tertiary care. This was demonstrated in the inclusion of American Physical Therapy Association in the Healthy People Consortium that assisted in creating the Healthy People 2010 goals for disability and its secondary psychosocial problems, nutrition and overweight, physical fitness and activity (PF-PA), tobacco use, arthritis, osteoporosis, and chronic low-back pain (LBP), heart disease (HD) and stroke among others (8). For the purpose of this study, four of these health areas were explored; LBP and arthritis, nutrition and overweight, PF-PA, and HD and stroke, which are all common problems related to physiotherapy in Nigeria.

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Social cognitive theory (SCT) refers to a psychological model of behaviour that emphasizes acquisition of social behaviours and learning through observation (9). SCT describes a multifaceted causal structure in which selfefficacy beliefs operate with outcome expectation (OE)
in the regulation of human motivation (10). The theory has been applied broadly to areas such as career choice, organizational behaviour and motivation (11-13). In SCT, a person’s on-going functioning is a product of a continuous interaction between cognitive, behavioural and contextual factors. In addition, learning and the demonstration of what has been learnt are distinct processes
(14). This suggests that an individual may have acquired knowledge in an area of practice but may not be able or willing to apply it. This could be due to low self-efficacy in the skills and expertise required, or to perceived negative OE from the application of the knowledge. For example in school nurses’ practice to prevent childhood obesity, perceived barriers was found to partially mediate the influence of self-efficacy (15). Thus, the SCT model can provide an understanding of the of HP practices among physiotherapists, and for developing strategies to manage any possible barriers.

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According to Bandura (16), self-efficacy is the confidence in being able to make the behaviour changes necessary to reach a desired goal. It influences the likelihood of a behaviour being initiated and sustained despite poor outcomes (17). For instance, a physiotherapist with high self-efficacy in prescribing exercises for osteoarthritis or low-back pain may be more consistent in making the prescription. Contrary, low self-efficacy due to lack of confidence or preparation may lead to withdrawal from the practice (17). Poor self-efficacy has been found to be a common barrier to adherence to practice guidelines among physicians (17). OE is the extent to which a health professional believes that a particular task or behaviour change will result in a specific outcome (16). For example, many smokers are not counselled to quit during a physician visit (18) despite the fact that most physicians agree with the recommendation to provide smoking cessation counselling (19;20). An important reason for this non-adherence is a belief that the intervention will not
have an effect (21). This negative OE may hinder health professionals in following the recommended practice even when self-efficacy is high.
 

The aim of this study was therefore to explore HP practice, self-efficacy and OE among Nigerian physiotherapists in addressing arthritis and LBP, nutrition and overweight, PF-PA, and HD and stroke.

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Method
Design and Participants

 This cross-sectional survey involved 110 physiotherapists out of about 200 clinical physiotherapists who had practised for at least two years in 12 randomly selected Nigerian federal teaching hospitals across the six geographical zones of the country. The hospitals were selected out of a total of 20 federal teaching hospitals using a proportionate stratified random sampling method. All the participants gave informed consent to participate in the study.

 

The Yaro Yamane formula (22) was used for estimating the sample size for the study (0.05 level of significance). This resulted in a total of 133 participants, so unfortunately the study fell short in reaching the required sample size.  

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Procedures

An adapted questionnaire originally developed by Rea et al (23) was used in this study. Initially, the questionnaire was pilot-tested among 10 Nigerian physiotherapists, who gave feedback regarding ease of understanding and answering the items in the questionnaire, and their suitability for the Nigerian setting. A second administration of the same questionnaire was carried out to ascertain
the consistency of the questionnaire sum scores. A total of 150 questionnaires were sent out to physiotherapists in the selected hospitals through identified contacts, who were also physiotherapists in the hospitals. A cover letter was included explaining the purpose, procedures, risks and benefits, and the voluntary nature of involvement in the study. The questionnaires were also accompanied with addressed and stamped envelopes to facilitate the return of the questionnaires. Out of the 150
questionnaires, 110 were returned (73% response rate).

 

The questionnaire included four sections: demographic and practice characteristics, HP practice, self-efficacy for HP and OE from HP. The questionnaire was adapted to the four health areas (nutrition and overweight, PFPA, arthritis and LBP and HD and stroke) examined in this study. The demographic and practice details included
age, sex, qualifications, area of interest and years of practice.

The Ethics Committee of the Nnamdi Azikiwe University Teaching hospital Nnewi approved the procedures employed in this study.

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HP Practice
The HP practice section encompassed the percentage of patients that, in the last month, had a particular problem (e.g. what percentage of your patients do you asses to have low PF-PA?), percentages of time the patient with such a problem was assisted (e.g. what percentage of time do you assist patients with low PF-PA to get more physically active?), listened to (e.g what percentage of
time do you listen to patients with low PF-PA?), referred (e.g what percentage of time do you refer patients with low PF-PA to appropriate experts?), educated (e.g what percentage of time do you educate patient with low PFPA on being physically active?), and goals were developed and set for them (e.g what percentage of time do you develop and set goals for patients with low PF-PA?).

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Self-Efficacy
The self-efficacy section covered 12 items including the level of confidence the physiotherapist had in assisting the patient: 1) when the patient was aware of the problem, 2) when the spouse or partner was not supportive of the patient, 3) when more time was allotted per patient than currently available, 4) when the physiotherapist was adequately educated to address the problem, 5) when the physiotherapist had observed another colleague helping the patient for the problem, 6) when the physiotherapist did not have the support of the referring clinician, 7) when the physiotherapist had the proper supportive materials to assist the patient, 8) when the problem interfered with a physiotherapy goal, 9) when the patient was already seeing a professional for the problem, 10) when the physiotherapist had an appropriate source to refer the patient to for assistance, 11) when the patient had low socioeconomic status and 12) when there was a language barrier. The self-efficacy score was measured on a four-point-likert scale with the highest score indicating that the physiotherapist was very sure he or she could assist. Self-efficacy items that were inherently negative such as “when partner/family is not supportive” were conversely coded.

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Outcome Expectation
The OE section included four items. These items were likely perceived outcomes of intervention that might influence the extent to which the physiotherapist would be ready to assist the patient for HP: 1) the patient develops more positive feelings and increased satisfaction with life, 2) the patient is able to address and achieve physiotherapy goals more readily, 3) the physiotherapist feels he addresses an issue that is beyond the normal scope of practice 4) the patient’s rapport with the physiotherapist is weakened or hindered. The OE score was measured on a five-point-likert scale with the higher score indicating a good outcome and the lower score indicating a bad outcome. Scores for negative outcomes such as “patient rapport is hindered/weakened” were conversely
coded to indicate a higher sum as a positive or “good” outcome.

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Statistical Analysis
The data were summarized using mean and standard deviation (SD) or frequency and proportion. The percentage scores for self-efficacy and OE were measured on the total item scores contra the total score by the maximum obtainable score for each. Relationships between each of the components of HP practice in the four health areas, and each of self-efficacy and OE scores, were tested using the Spearman-rank order correlation. Similarly, relationships between self-efficacy and corresponding OE were tested using the Spearman-rank order correlation. A p-value < 0.05 was considered significant. All analyses were carried out in SPSS version 20.

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Results
Table 1 shows the characteristics of the 110 physiotherapists included in the study. The mean age was 34.9 years (SD±6.47years). About half of the physiotherapists (53%) had practised for less than 10 years. 53% of the physiotherapists were men and had interest in orthopaedic conditions (38%). A vast majority had the basic degree (84%).

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