Primary Health Care: Open Access

Knowledge Attitude and Practice of Primary Health Care among Nigerian Physiotherapists

Ganiyu Oluwaleke Sokunbi^1*, Anita Okafor², Stanley Maduagwu³, Abdullah Saleh¹ and Chris Udoka Okafor^{4 *}Correspondence: Ganiyu Oluwaleke Sokunbi, Physiotherapy Department, Bayero University, Nigeria, Email:

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Introduction

Primary health care (PHC) was defined as a grass-root approach towards universal and equitable health care for all [1]. This strategy is meant to address the main health problems in the community via preventive, curative and rehabilitative services [2]. It is an essential health care delivery platform, which should be based on practical, scientifically sound and socially acceptable methods and technologies that are equitable and universally accessible to all individuals. Physiotherapists are primary health care professionals who use approaches that intend to promote, maintain and restore physical, psychological and social well-being to address the main health problems in the community via preventive, curative and rehabilitative services [2-4].

Nigeria is a signatory to the Alma Ata declaration. However, physiotherapy services are currently, available in big cities in Nigeria [5]. These services are only accessible to a few. Many who do not live in these big cities or do not have the means of travelling to big cities typically do not get physiotherapy services. Eventually they resort to staying at home, and/or they consult quacks and local traditional healers, only to present in the city hospitals, often too late with an almost irreversible deformities and complications that could have been prevented by early intervention [5].

Emphasis for the greater involvement of physiotherapists in PHC arose from the fact PHC system in Nigeria is not yet adequately sensitized to promoting preventative measures needed to combats chronic non communicable diseases, the health care needs of the elderly and people living with Disability (PLWD) [5]. Many of the home bound PLWD and the elderly in our rural communities generally suffer from multiple and chronic communicable and non-communicable diseases (CD & NCD) and frequent falls are in need of longterm constant care. It appears that there are no deliberate implementation plans via the PHC program in Nigeria geared towards provision of rehabilitation intervention, advance care services, and promote independent living of the elderly and PLWD [5].

Rendering quality PHC services require multi-skilled Health Care Providers with good knowledge of PHC, positive attitude towards PHC and ability to deliver a one-stop package of care. Thus, understanding the levels of knowledge, attitude and practice of PHC among physiotherapists could enable a more efficient process of awareness, creation and bringing to light the issues of strength, weakness, opportunities and threat amongst physiotherapists regarding their roles in PHC, which in turn could form a solid foundation for the integration of physiotherapists into the National primary health care program and Health care agenda of the global millennium developmental goals. Due to the minimal scientific reported evidence, it is important to determine the extent Knowledge, practice and attitude towards PHC among Physiotherapists in Nigeria.

Materials and Methods

The Study design was a cross-sectional, descriptive study conducted between March and August 2018 to explore the knowledge, attitudes and practice of PHC among Nigerian Physiotherapists in Kano, Northwestern Nigeria.

Purposive sample of qualified physiotherapists in Kano Metropolis was adopted for this study. A total population sampling size whereby every practicing physiotherapists, that are willing to participate and met the inclusion criteria, were recruited into the study. The inclusion criteria for participation include physiotherapists registered with Medical Rehabilitation Therapist Board (MRTB) of Nigeria. MRTB is a federal agency that regulates the practice of physiotherapists and other allied health care professionals in Nigeria. Participants must have completed the compulsory one-year post-qualification internship in any MRTB recognized Health facilities, took part in the one year post-internship National Youth Service corps (NYSC) program and currently practicing in any of the secondary or tertiary health care facilities within Kano metropolis, Kano-State, Nigeria. The Health care facilities were Amino Kano Teaching Hospital, Kano, National Orthopedic Hospital, Abdullahi Wasai Specialist Hospital, Murtala Muhammad Specialist Hospital and Sir Muhammad Sunusi Specialist Hospital. All the hospitals are based in Kano Metropolis.

Data Collection Questionnaires

Sociodemographic questionnaire

A Researcher developed questionnaire was used to collect participants’ sociodemographic variables.

Knowledge, attitude and practice (KAP) questionnaire on primary health care

KAP of PHC Questionnaire was adopted from PHC questionnaire developed for the evaluation of primary health care in Nigeria [6]. It was used to assess the knowledge, attitude and practice of PHC among physiotherapists. The questionnaire is made up of three sections (A, B, and C). Section A is made up of 35 questions on knowledge of physiotherapist on primary health care. Section B is made up of 33 questions on attitude of physiotherapists towards primary health care. Section C asked the physiotherapist to indicate areas where he/she has been involved in PHC in the past or present in open ended format. The questionnaire took 10-15minutes to complete.

Scoring

The scoring was carried out as previously described by Ogaji et al [6].

Section A: Each question in this section received a score of 1 mark for correct response and no mark for an incorrect response. For items number 4, 9, 16, 21, 29, 30, 32 and 33 ‘not true’ responses will be the correct answers and attracted a score of one (1) each. For the rest of numbered items, a ‘true’ response attracted a score of one (1). A sum total of scores in this section will give a total knowledge score of PHC.

Section B is made up of questions on attitude towards primary health care. This section has four levels of responses strongly agree, agree, disagree and strongly disagree with corresponding scores of 4, 3, 2 and 1 respectively.

Section C asked the participants to indicate areas where they have been involved in the practice of PHC in the past or present; it is an open ended format response.

The total and the percentage score of each section A and B were calculated for individual participants and the mean percentage scores for all the participants on knowledge and attitude were calculated to indicate the level of knowledge of PHC and attitude towards PHC respectively. The Higher the scores on knowledge and attitude, the better the knowledge and attitude toward PHC [6].

Psychometric properties

KAP of PHC Questionnaire has been reported to have internal consistency reliability estimates (Cronbach’s alpha) of .76 for the 35 knowledge items and .85 for the 34 items on the attitude scale [6].

Questionnaire administration

Participants were met at their respective places of works at their chosen convenient time for this purpose. The study questionnaires were administered by hand by the researcher to the participants who were given 24-hours to complete the questionnaire and return it back to the researcher by hand.

Data analysis

Descriptive statistics of frequencies, mean, standard deviation, frequency and percentage were used to summarize sociodemographic data. Scores on knowledge, attitude and practice of PHC were calculated and summarized as percentages [(scores obtained due to correct responses/total scores possible due to correct responses) x 100. Normality of distribution of the data obtained on percentage scores for knowledge and attitude were tested. Shapiro-Wilk Test showed that percentage scores for knowledge and attitude of primary Health care among the participants showed symmetrical distribution (P >0.05). Thus, mean % scores (SD) for knowledge and attitude of PHC were calculated. Areas of practice of PHC as indicated by the participants were presented as Frequency and Percentages. The relationship between years of working experience and each of knowledge, attitude and practice of PHC were tested using Chi square. The statistical analysis was performed using Statistical Package of Social Science (SPSS) version 20. Level of significance was set at alpha level of 0.05.

Results

Questionnaires for the data collection for the present study were distributed to 65 physiotherapists who met the inclusion criteria, 61 out of 65 returned the questionnaires within 72 hours from the time of questionnaire distribution, yielding a response rate of 93.8%. All the participants have entry-level BPT degree while only 42.6% of the participants had postgraduate qualifications. Majority of the participants 40 (65.6%) of the participants were below the age of 31 years. Thirty-nine (63.9%) of the participants were male. Among all, 39.4% have either acquired 5 or more years working experience as physiotherapists. All the participants in this study practice in Governmentowned (Public) Health Care Facilities. Out of all participants, 50.8% practice in tertiary health care facilities while 49.2% practice in secondary health care Facilities (Table 1).

Table 1: Sociodemographic variables of the participants.

Knowledge, attitude and practice of primary health care (PHC) among physiotherapist

Table 2 shows that the mean percentage scores for the knowledge of Primary Health care among physiotherapists ranged from 67% to 98% with an average score of 76.44 ± 7.85%. Participants with the lowest scores in attitude towards PHC recorded 59% while the participants with highest score recorded 69%. The mean percentage score for the attitude towards PHC was 61.45 ± 5.98% (Table 2). The different areas of practice of PHC as indicated by the participants are presented in Figure 1. Less than half (42.6%), of the physiotherapists that participated in this study reported to have been involved in the practice of PHC during their years of working experience. More than half (57.4%) of the total number of the physiotherapists have not practiced in PHC program. In term of areas of practice of PHC, 32.8% have been involved in Health promotion via Physiotherapy Community outreach health promotion program while 9.84% said they were uncertain of their areas of previous practice in PHC program.

Table 2. Percentage and percentage mean scores for knowledge of primary health care and attitude towards primary health care among physiotherapists.

Figure 1. Areas of physiotherapistsâ?? practice of primary health care.

Association among years of practice, level of academic qualification, attitude and knowledge of PHC among physiotherapists

Table 3 shows the results of the Chi square analysis of the association among years of practice, level of academic qualification, attitude and knowledge of PHC among physiotherapists. There was no statistical significant association between; knowledge of PHC and year of practice (χ² = 42.42 and P = 0126); knowledge of PHC and level of academic qualifications (χ² = 11.52 and P = 0.401). Similarly, there was no significant association between; attitudes toward PHC and year of practice (χ² = 72.117 and P = 0.749); attitudes toward PHC and level of qualifications (χ² = 33.887 and P = 0.170).

Table 3. Association among years of practice, level of academic qualification, attitude and knowledge of PHC.

Discussion

This article presents a descriptive study of knowledge, attitudes, and practice of PHC among physiotherapists in Nigeria. In general, the majority of physiotherapists had good knowledge of PHC and very high scores in attitudes, indicating positive attitudes towards PHC. However, the high knowledge of PHC and positive attitude towards PHC did not commensurate with the low level of involvement in terms of practice among the physiotherapists in this present study.

Findings from this present study showing rather high knowledge of PHC and a rather positive attitude towards PHC is consistent with the reports by Dionne et al. [7], who reported that Physiotherapists have the high knowledge, skills and attitudes to actively participate in PHC by focusing on health promotion, disease prevention and interventions that improve or maintain the health and quality of life. It could also mean that physiotherapists working in Kano Metropolis are well positioned for integration into the National Primary Health Care Delivery System.

It seems that there are not many reports on the findings on studies on the knowledge and attitudes towards PHC among physiotherapists, thus limiting comparisons of the findings of our study. However findings from studies carried out in Nigeria, Ghana and South Africa, on knowledge and attitude toward Health promotion among physiotherapists have been consistent in terms of Physiotherapists having high knowledge and positive attitude towards health promotion [8-10].

One of the findings from this present study is low level of practice and involvement of physiotherapists in PHC, this finding is at variance with previous findings of studies that have consistently associated high level of knowledge and attitude with high level of practice of health promotion in Africa [8-10]. Health promotion being an integral part of PHC, one would have expected a similar trend in the findings in terms of increase practice with increase knowledge and attitude in PHC among physiotherapists. However the concepts and the responsibilities attach to PHC is broader than that of health promotion. PHC was defined as a grass-root approach towards universal and equitable health care for all [3]. The strategy of PHC is meant to address the main health problems in the community via preventive, curative and rehabilitative services. Health promotion on the other hand is concerned itself mainly with the process of enabling people to improve and increase control over their health [2,11].

The low level of practice of PHC could be partly due to lack of understanding of the concept, responsibilities attached to the practice of PHC among the physiotherapists who participated in this study, as opined to by some of the participants, who reported that they have been involved in PHC but could not clearly define their specific areas of involvement. It could also mean that the physiotherapists though have a good knowledge but poor practice because of lack of understanding of the implementation of their role in PHC. This finding again bagged the question of whether despite the growing interest of in PHC, do Nigerian physiotherapists have a clear understanding about opportunities and ever evolving roles of physiotherapy in PHC delivery system?

It is important to match the growing interest of physiotherapists in PHC with understanding of the concept, value and the responsibilities associated with been a primary health care provider.

Consistent rising cost of acquiring quality health care service in Nigeria as well as increasing have necessitated a need to increase accessibility of quality health to both urban and rural areas. The goal of achieving easy and universal accessibility, a cardinal principle of PHC, could not be said to have been achieved in the rural populations in Nigeria who are seriously underserved with physiotherapists when compared with their urban counterparts5. Thus, available, accessible and affordable physiotherapy service at PHC level will undoubtedly leads to a healthier population and sustainable health system outcomes [12]. It has been reported that in situations where this integration had occurred the results obtainable will be in the form of increase levels of satisfaction with service by both the patients and the physicians, decreased wait times increased cost effectiveness, reduced rates of referral to specialists, and improved outcomes for patients including quality of life measures [12]. Lack of knowledge could have been thought to be a possible barrier to the practice of PHC and vice-versa, on the contrary, the results of the present study show that physiotherapists have good knowledge and good attitude of PHC but poor level of practice of PHC. Our findings also showed that post entry level qualifications and years of experience of practice have no influence on knowledge and attitude to PHC. These finding bagged a question of what is the exact nature of knowledge that is needed to integrate physiotherapists into the practice PHC. It could perhaps be that complimenting the formal knowledge acquired in the classroom with skills in case management and other forms of informal knowledge will be what is needed to improve on the current level of practice of physiotherapists in PHC. It could also be that knowledge that will empower physiotherapists’ with diagnostic and referral skills will be needed to compliment the therapeutic skills they have formally acquired during their entry level training to enhance their abilities for a more autonomous practice in the community at PHC level. Cott et al [12] opined that diagnostic, therapeutic and referral skills based knowledge will enable physiotherapists’ to take on more diverse and integrative roles, such as those necessary in the management of complex needs and chronic diseases in the community.

Physiotherapy regulatory and professional bodies in Nigeria and different Institutions of learnings might need to organize series of short training and continuous education on PHC courses focused on practice of physiotherapists in the community especially in the rural and urban areas in order to improve understanding of the roles, values and promote practice of physiotherapists in the PHC.

Government policy should also become well aligned with professionals’ aspirations to increase the practice of physiotherapists at PHC. Such a policy should make it mandatory for every Health facilities in the rural and urban communities to provide physiotherapy services. Government could also make available funding to assist and encourage individual physiotherapists who might want to set up a private physiotherapy clinic in the communities currently devoid of such services.

Implications of the findings

Findings from this study add credence to the fact that Physiotherapists, physiotherapy Regulatory Agent and Professional Bodies, Physiotherapy Institutions of learning and Government Authority on PHC in Nigeria should provide impetus for the integration of physiotherapy into the National primary health care program and increase participatory level of physiotherapists in the PHC in order to attain the global millennium developmental goals.

Limitation of this study

The present study is limited in terms of the number of participants. The study was delimited to physiotherapists practicing in Kano Metropolis. Future studies should involve proportional representatives / sample of physiotherapists form the six geopolitical zones of the countries.

Future studies could consider the use of structured interview to explore the experience of the physiotherapists on the practice of PHC, explore facilitators and barriers factors to the practice at PHC level among physiotherapists.

Conclusion

Physiotherapists in the Kano Metropolis of Kano-State, Nigeria, have good knowledge and attitude of Primary Health Care but poor practice in terms of level and scope of involvement in PHC. Levels of qualification and years of working experience have no influence on knowledge and attitude towards PHC.

Ethical Considerations

The Ethical Approval for this study was sought and obtained from the Ethical Research Committee of all the Hospitals where the survey was carried out, i.e. Amino Kano Teaching Hospital, Kano, National Orthopedic Hospital, Dala, Abdullahi Wasai Specialist Hospital, Murtala Muhammad Specialist Hospital, and Sir Muhammad Sunusi Specialist Hospital. Witten Informed consent was sought and obtained from all the participants.

References

1. Qureshi, A.K., et al. “Strategies for enhancing the use of primary health care services by nomads and rural communities in Saudi Arabia.” East Medit Heal J 2.2 (1996): 1-5.
2. Alenoghena, I., et al. “Primary Health Care in Nigeria. Strategies’ and Constraints in Implementation.” Int J Comm Res 3.3 (2014): 74-79.
3. World Health Organization (WHO). “PHS capacity-building strategies.” Public Health Report Series, Geneva 106.1 (1991): 5-15.
4. Alma-Ata “Primary health care.” World Health Organization, Geneva (1978).
5. Sokunbi, G.O. “Opportunity of physiotherapist in PHC in Nigeria.” Nigerian J Med Rehab 19 (2017): 1-4.
6. Ogaji, D.S., et al. “Development and validation of the patient evaluation scale (PES) for primary health care in Nigeria.” Prim Health Care Res Dev 18.2 (2016): 161-182.
7. Dionne, F., et al. “The challenge of obtaining information necessary for multi-criteria decision analysis implementation: the case of physiotherapy services in Canada.” Cost Effect Res Alloc 11.11 (2013): 2-16.
8. Abaraogu, U.O., et al. “Knowledge, Attitudes, and the Practice of Health Promotion among Physiotherapists in Nigeria.” Physio Canada 71.1 (2019): 92-100.
9. Joseph, P.M. “Knowledge, attitudes and practices of physiotherapists regarding their role in health promotion in Gauteng Province, South Africa.” University of Limpopo Institutional Repository, Faculty of Sciences, School of Health Sciences, Theses and Dissertations (Public Health), University of Limpopo (Medunsa Campus). Retrieved from http://hdl.handle. net/10386/446
10. Boakye, H., et al. “Knowledge, attitude and practice of physiotherapists towards health promotion in Ghana.” South African J Physio 74.1 (2018): a443.
11. Higgs, J., et al. “Portrait of the physiotherapy profession.” J Interprof Care 15.1 (2001): 79-89.
12. Cott, C.A., et al. “Models of integrating physiotherapists into family health teams in Ontario, Canada: challenges and opportunities.” Physio Canada 63.3 (2011): 265-75.