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International Journal of Physiotherapy and Rehabilitation, October 2010, Vol.

1, Issue 1, 09-18 Indian physiotherapists’ perceptions of factors that influence the adherence physiotherapy treatment K. Marwaha, H.Horabin, S.M.McLean

Indian physiotherapists’ perceptions of factors that influence the adherence of Indian patients to physiotherapy treatment recommendations.
Faculty of Health and Wellbeing, Sheffield Hallam University, Sheffield, UK, S10 2BP Email: s.mclean@shu.ac.uk

Abstract
Background: Non-adherence to treatment is common and costly. Outside western culture little is known about the reasons for non-adherence with physiotherapy. This qualitative, grounded theory, focus group study investigated physiotherapists' perception of the factors affecting nonadherence of patients to physiotherapy treatment in India. Method: Six practising physiotherapists from New Delhi, India, formed a focus group and were invited to discuss their views regarding factors influencing patient non-adherence and their strategies to cope with these factors. The dialogue was transcribed and analysed. Significant statements/ words describing non-adherence were identified and clusters of meaning developed and used to write a composite, thematic description presenting the essence of the discussion. Results: The major factors identified were: poor awareness of physiotherapy and poor infrastructure, time, economic factors, social and cultural factors and poor communication. Patient and family education formed the basis for many of the strategies identified by physiotherapist to help them manage non-adherence. Conclusion: Physiotherapists in India recognise some barriers to adherence and have strategies that they perceive as helpful in encouraging motivation that are unique to the Indian social context. Other barriers to adherence and strategies recognised as key to improving adherence in western countries were not recognised by this group. Keywords: Adherence, barriers, physiotherapist perception

Introduction
Adherence has been described as “the extent to which a person‟s behaviour corresponds with agreed recommendations from a healthcare provider” (WHO 2003). In Western countries nonadherence with treatment recommendations is a problem across all health care disciplines including physiotherapy (Vasey 1990; Friedrich et al 1998; Campbell et al 2001). For example, only two-thirds of patients were adherent with short-term exercise recommendations (Sluijs et al 1993) and this may be worse for long-term treatment recommendations and unsupervised home-

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Indian physiotherapists’ perceptions of factors that influence the adherence physiotherapy treatment K. Asian women are also less likely to take regular exercise than White or Afro-Caribbean women (Lip et al 1996). S. prior to the commencement of the focus group. beliefs and behaviour around pathology or physical activity. The extent of non-adherence in the Indian population is not known. One study found that ethnicity was an inconsistent predictor of attendance at an exercise programme or continued exercising post-treatment in subjects with OA knee (Rejeski et al 1997). There may be many reasons for patient non-adherence. Sluijs et al 1993. greater number of perceived barriers to exercise and increased pain levels during exercise are barriers to treatment adherence (Jack et al 2010). Prior to the study taking place participants had an opportunity to ask questions about the study. depression. Physiotherapists from different hospitals and clinics across Delhi were invited to participate in the study using information sheets sent via email. Ethnicity may also influence attitudes. Physiotherapists were considered suitable for the study if they worked in an outpatient department treating patients with musculoskeletal disorders. Setting and recruitment The venue for this study was a hospital in Delhi. Nelson et al 1995). Ethical approval was obtained from the Dissertation Management Group at Sheffield Hallam University. Those who agreed to participate signed a consent form. International Journal of Physiotherapy and Rehabilitation 10 .M. Participants Because of time constraints. helplessness. Participating physiotherapists were assured of confidentiality before the start of the focus group. low self-efficacy. had a minimum of three years work ©2010. anxiety. The role of ethnicity and culture in non-adherence are important areas for investigation. Marwaha. Methodology Study Design Qualitative methods using a grounded theory approach was used in this study. time and venue of the focus group. convenience sampling was used to identify suitable physiotherapists. Consequently Asian women may be less likely to adhere with treatment recommendations which encourage increased levels of exercise or physical activity. the Chinese display more negative beliefs regarding future consequences of back pain and more fear avoidant beliefs toward being physically active with back pain compared with white Australians (Burnett et al 2009). poor social support. low in-treatment adherence with exercise. For example. H. low levels of physical activity. A focus group of physiotherapists with experience of treating patients with musculoskeletal disorders was used to obtain information regarding perceptions of the factors influencing patient non-adherence. Potential participants were provided with the date. The physiotherapist‟s views were collated and recurring themes identified.McLean based exercise programmes (Reilly et al 1989. For example. Increasing understanding of these issues could help physiotherapists consider how ethnicity and culture might influence adherence within their own practice The aim of this study was to investigate physiotherapist‟s perception about factors influencing non-adherence in patients attending for treatment in musculoskeletal physiotherapy outpatient departments in India.Horabin. It is also possible that cultural and societal differences will impact upon adherence.

The participants and researcher sat around a table in full view of one another and were asked to express their opinions one at a time to ensure clarity of the information collected. but were able to offer some insights into the study aims. No moderators or extra observers were used which may have limited data collection. Procedure A pilot study was conducted at Sheffield Hallam University.Horabin. The interviewing guide was used to direct the discussion as required. Have you all come across patients who do not seem to follow your prescribed treatment? There could be various ways in which they do not adhere. The data was transcribed by the primary author (KM). Data collection Two recorders were used to collect data during the discussion in case of technical faults. H. if any? What are the strategies that you think help in dealing with patients to help them adhere to your prescribed treatment? What do you think can be done to avoid patients from going into non adherence in the first place? Table 1 Focus group interviewing guide In the main study one of the authors (KM) facilitated the focus group. S.M. 2) significant statements/sentences/words that described the factors influencing non-adherence ©2010. tone of voice etc which may have conveyed additional meaning to the data collected. The facilitator made field notes during the session.Indian physiotherapists’ perceptions of factors that influence the adherence physiotherapy treatment K. had less than three years of work experience or had no experience in an outpatient department. International Journal of Physiotherapy and Rehabilitation 11 . Can we name a few? What in your thinking are the reasons that act as barriers to adherence? What in your thinking are the motivational factors that enhance adherence. Data analysis Interview transcripts and field notes were analysed by the primary author (KM) in four stages: 1) a thorough reading of the transcribed data was conducted to gain a sense of the overall meaning. Since this was a focus group design the number of participants was limited to six to enable effective data analysis. Marwaha. since there was no observation of non-verbal language. UK to develop the interviewing guide shown in Table 1. thus providing useful insights into the role of Indian culture and society on non-adherence. Physiotherapists were not considered suitable for this study if they worked on wards or ICU‟s. This method of sampling provides access to practising physiotherapists dealing with non-adherence on a daily basis. In order not to lead participants views she did not contribute any ideas to the discussion.McLean experience and were fluent English speakers. Information was collected about physiotherapists‟ perceptions regarding factors affecting patient non-adherence and the strategies they would recommend to facilitate adherence. Participants in the pilot study were physiotherapists studying for a Masters degree in Applying Physiotherapy. these physiotherapists may not have met all the criteria to participate in the study.

This may have helped the participants to discuss their perceptions more openly. Results Of the six participants. Even where patients have undergone rigorous physiotherapy allowing. Reflexivity The primary researcher (KM) is from the same race. Participants perceived that the Government and doctors. Patient information should be accessible and comprehensible to the population with low literacy. During the course of the study. may also have an important role in creating awareness about the availability and benefits of physiotherapy. this may also have helped the primary researcher to identify with and interpret the participants‟ views and accurately reflect the reported factors and strategies. All care was taken to ensure that the researchers‟ views did not influence the participants or discussion. Many people seem unaware of treatment strategies which might be helpful for their conditions. the other had more than 30 years of clinical experience. this was attributed to high rates of illiteracy in India where only a small section of the urban population are educated and equipped sufficiently to find out information about their condition. The majority of the population seem to be unaware of various government schemes to help the less affluent to access physiotherapy. lack of disabled-friendly infrastructure and low prioritisation for improved infrastructure by Government was identified as hindering access to physiotherapy and other medical amenities. S. At the beginning of the study. Inadequate public transport. Many unauthorised residential colonies with narrow lanes cause difficulty for vehicle access creating potential problems for accessing physiotherapy clinics. Due to study constraints only one researcher was used to transcribe and analyse data. for example.M. Marwaha. H. 4) a composite description of each theme was collated in order to further explore and discuss inferences of the themes. Six main themes emerged from the discussion. Of these one had more than 20 years of experience in various Government/private/semi-private hospitals and clinics. Two participants were male and four were female. International Journal of Physiotherapy and Rehabilitation 12 .Indian physiotherapists’ perceptions of factors that influence the adherence physiotherapy treatment K. the primary researcher had little experience of dealing with nonadherent patients and low understanding of the extent of non-adherence and the factors which might influence it. which could lead to inconsistencies in the interpretation of the data.Horabin. Many people are not aware of physiotherapy centres in their locality or are not aware of the aim of physiotherapy to bring about independence for patients and their families. cultural background and originating city as the study participants.McLean were highlighted. who play an important role in patient education. Simultaneously. Poor awareness of physiotherapy and poor infrastructure Poor awareness of physiotherapy was identified as a barrier to patient‟ attendance by most participants. independent ©2010. four had more than five years of experience. 3) clusters of meaning were developed from significant statements into themes. All inference drawn from the data are presented with supporting evidence where possible. the literature related to non-adherence was reviewed leading to the researcher acknowledging the various issues related to non-adherence and developing a deeper insight into the problems encountered by physiotherapists in her home country of India.

Indian physiotherapists’ perceptions of factors that influence the adherence physiotherapy treatment K. This barrier was thought to be changing. Marwaha. Patients often admit to visiting “saints” and “babas” who promise them cure to help them get back to normal quickly. H.M. Social and cultural factors Family obligations were identified as another barrier to treatment. economic factors may act as a barrier to attending physiotherapy. Such deep-seated cultural beliefs are beyond the scope of a single profession such as physiotherapy. Participant identified that the role of educating patients and families regarding the promotion of independence was particularly important in the Indian culture where dependency on family is high. International Journal of Physiotherapy and Rehabilitation 13 . though the use of charts/diagrams may help them remember their exercises. Another solution proposed was encouraging “goal-oriented” exercises such as giving an Indian woman functional tasks of rolling dough balls with a pin so that she can see for herself any improvement. the participants described the prevalence of the “purdah” system in many parts of India whereby the daughter-in-law stays under a veil and is bound so deeply by her daily chores that her need for physiotherapy is not considered a priority because the money spent does not represent good value. poor access may mean that patients may not be able to enjoy their life in a wheelchair and this may discourage patients from undergoing further physiotherapy. It was suggested that domiciliary physiotherapy might ease some of these issues. It was also recognised that patients have a tendency to forget their exercises. This may prevent many women having access to physiotherapy. Time Participants agreed that physiotherapy is time consuming and that patients need to alter their daily routine or take time from work. The participants suggested that increasing awareness about Government schemes and introducing home-based exercise. and at times other basic medical amenities. The addition of more home-based programs could allow patients to reduce some of the time required for attending treatment. This may encourage dependency and maintain disability. but change of this kind and the “up-lifting” of women in the family may take time.McLean mobility using a wheelchair. Another cultural barrier identified was the “stigma” attached to disability by society and the popular belief that a person suffers from disabilities because of past “karma”. Economic factors Participants identified that since much of India is below the poverty level. S.Horabin. Many cultural barriers were also identified. though it was agreed that this would be an excessive financial burden on the health sector. One participant suggested that this was due to “lack of patience in patients”. family or social obligations to attend the department for treatment which may be difficult for many patients. One example was that because of love and concern. For example. For most patients physiotherapy treatment is not covered by insurance and cheaper alternatives are often sought. domiciliary physiotherapy or physiotherapy assistants might help to tackle issues of cost. It was suggested that patients also need to be well informed and involved in the treatment planning to allow flexibility in the treatment process and increase their confidence in treatment. help is available within the family. ©2010. which may prevent a patient from doing even simple tasks for themselves.

Horabin. This may influence patients who may then be unwilling to deviate from the GP recommended protocol thus creating strains on the patient-therapist relationship. Some participants suggested that this scenario may be changing and that therapists are getting better at communicating with doctors and supporting changes in treatment with evidence.Indian physiotherapists’ perceptions of factors that influence the adherence physiotherapy treatment K. he may find five different treatment approaches. Physiotherapists often have different professional approaches which can create confusion for patients. Cost of treatment was also identified as a reason for nonadherence in patients attending private physiotherapy practices in Holland (Sluijs et al 1993) and the USA (Alexandre et al 2002). H. S. For example. British (Campbell et al 2001). Other barriers were identified which may be specific to India. Consequently therapists may be unwilling or unable to change doctors‟ recommendations and continue the treatment programme without regard for treatment outcome. In particular Asian women may be less likely to take regular exercise than White or Afro-Caribbean ©2010. Those GPs that do may enforce their own treatment plans. if the patient sees five different therapists. Time issues associated with work or family commitments and forgetfulness have also been identified by Spanish (Medina-Mirapeix et al 2009). Some suggestions for alleviating the cost of physiotherapy and improving uptake of physiotherapy in India were to ensure that patients have self-management strategies for continuation at home. However previous studies have also observed that asking patients to adhere with home-based exercise can be problematic (Reilly et al 1989. Standardisation and regulation of education and practice may be beneficial to ensure equity of care. Most participants identified that many GPs do not acknowledge physiotherapy. International Journal of Physiotherapy and Rehabilitation 14 . They justified this variation by adding that an individual therapist‟s clinical experience and perception of the condition may cause them to deviate from following a fixed protocol. Poor communication Poor communication was identified by all participants as a barrier to adherence with communication gaps or poor relationships sometimes existing between therapist and patient or between therapist and referring doctor. This may arise in part due to language. They identified that variations in practice could also be due to poor or inconsistent standards of education in practice. time and treatment cost were identified in this study as barriers to poor adherence with physiotherapy treatment. Nelson et al 1995). Marwaha. social or intellectual differences. American (Alexandre et al 2002) and Dutch patients (Sluijs et al 1993). Participants suggested that treatment recommendations also need to be justified to the patients to provide a credible intervention and build more trust in the profession. Forgetfulness. Some barriers were identified which may be common to patients of all nationalities. Discussion This study examined the perceptions of Indian Physiotherapists about factors influencing adherence of patients to physiotherapy treatment.M. though it is likely to be a variable barrier depending on how physiotherapy is funded in different countries.McLean Participants suggested that a greater effort on the part of all medical professions and Government and non-Government agencies is required to address social and cultural barriers which are unhelpful for the health of sectors of the population.

However poor inter-professional communication may lead to poor inter-professional working. This may be true whether resident in India or not. for many patients. fit with the patients daily activities. bonds within the family. As far as we know.Indian physiotherapists’ perceptions of factors that influence the adherence physiotherapy treatment K. improve function and return to work (van Tulder et al 2000). alleviate symptoms or problems which are important to the patient (Campbell et al 2003). thereby preventing professional autonomy. It may also be helpful to ensure that advice and home-based treatment recommendations are credible. For example an American study found that after adjusting for educational attainment. it may be helpful to reinforce evidence that chronic pain patients who adhere with exercise therapy can achieve reduction in symptoms (Guzman et al 2002). this has not previously been identified as a threat to adherence. In addition. do not exacerbate pain (Jack et al 2010) and are interesting and enjoyable (Sluijs et al 1993). The issues that have emerged in this study indicate that some Indian physiotherapists may be moving towards autonomous thinking. poor understanding of the capabilities of other groups of health professionals and consequently ineffective delivery of healthcare programmes such as physiotherapy (Rushmer and Pallis 2003). low in©2010.Horabin. However. Within multi-cultural countries such as UK and USA adherence issues may vary with ethnicity. under the Medical Council Act (1956) physiotherapists in India work under medical direction. Marwaha.M. the use of communication booklets were found to be more effective for achieving effective communication and adherence in the white population compared with the non-white population (Post et al 2001). may be prevented from participating in physiotherapy or from undertaking rehabilitative exercises. Physiotherapist in this study identified a variety of issues which as far as we are aware have not previously been identified as barriers to adherence. given the deep-seated beliefs of such factors they may be present and act as a barrier to physiotherapy wherever in the world these ethnic groups reside. More recently the Paramedical and Physiotherapy Central Council Bill (2007) refused approaches made by the Indian Association of Physiotherapists to grant permission to remove the words „medical direction‟ from the definition of Physiotherapy practice. the stigma of disability. H. S. International Journal of Physiotherapy and Rehabilitation 15 . Physiotherapists also identified that inter-professional communication was a potential threat to adherence. reaching such women may present a great challenge which is beyond the scope of the physiotherapy profession. This may present as a problem in organisations such as the Indian Health Service which has a hierarchical structure and where any attempts to flatten out that hierarchy may represent a perceived threat to power and influence of some health professionals (Rushmer and Pallis 2003). The role of ethnicity as a barrier to adherence is an area which requires further investigation in USA and Europe. because of family obligations or the presence of the “purdah” system. A particular problem emerges for women who. Previous low levels of physical activity.McLean women (Lip et al 1996) and therefore less ready to adhere with treatment recommendations which encourage increased levels of exercise or physical activity (Jack et al 2010). At this time. Various social and cultural factors. such as the familial obligations of many Indian women. a belief in other forms of alternative treatment may be unique to certain Asian cultures. which have large Asian populations. suggesting that mode of communication of treatment recommendations may be an important consideration in areas where multicultural populations co-exist. Several factors identified in the adherence literature were not advanced by the physiotherapists in this study. For example the impact of a variety of patient related psychological and sociodemographic factors were not discussed.

the stigma ©2010. S. poor social support. frequency of undertaking prescribed exercise. help patients to resolve their difficulties and facilitate greater treatment adherence (Sluijs et al 1993). All of these factors are worthy of further investigation. This study has identified several factors surrounding non-adherence/non-attendance to physiotherapy in India. time and cost of treatment. forgetfulness. bonds within the family. International Journal of Physiotherapy and Rehabilitation 16 . greater number of perceived barriers to exercise and increased pain levels during exercise are all barriers to treatment adherence (Jack et al 2010). MedinaMirapeix et al 2009). The credibility and effectiveness of advice/treatment/exercise have been identified as important issues which may influence whether patients adhere to treatment recommendations (Sluijs et al 1993. though their relevance to Indian society has not yet been established. At the same time. Factors were identified which may be unique to India and to date have not been identified in western cultures e. why patients do not attend appointments etc. low self-efficacy.g. the concept of adherence is multi-dimensional (Kolt et al 2007) and could relate to attendance at appointments. under-researched and difficult to address. cultural or societal perspectives which have to date been minimally investigated and which may need to be considered in order to enhance treatment adherence and effectiveness. the familial obligations of many Indian women.McLean treatment adherence with exercise. this study provides an insight into the issues encountered by Indian physiotherapists and possibly the limited understanding which physiotherapists may have about a topic which is highly complex. This study investigated adherence in its widest sense. undertaking prescribed exercises. Future research should consider adherence in relation to a single dimension e. Conclusion This is the first study of its kind investigating Indian physiotherapists‟ perspective for why patients find it difficult to adhere to physiotherapy recommendations. The physiotherapists‟ perception of barriers to patient adherence may be different from those expressed by patients or identified by quantitative research. anxiety. following advice. More detailed qualitative studies investigating the views of physiotherapists and patients across the globe would enhance our understanding of racial. Factors were identified which appear to be common to all nations e.M. helplessness.g. Campbell et al 2001. depression. Within physiotherapy. Marwaha. H.Horabin. Being aware of all the possible reasons why patients may not adhere to treatment recommendations may help therapists to carefully enquire about the kinds of problems patients are experiencing. correct performance of exercises or doing more or less than advised.g. The addition of follow-up focus groups may have allowed fuller exploration of emergent issues. Study considerations The disadvantage of using a single focus group is that saturation may not be reached i. The barriers to each aspect of adherence may be different.Indian physiotherapists’ perceptions of factors that influence the adherence physiotherapy treatment K. physiotherapists in this focus group may not have identified all possible factors perceived as contributing to patient‟ non-adherence. Therefore this study provides a perspective on the construct of adherence.e. This may be due to a lack of biopsychosocial health education within the undergraduate curriculum in India.

220-228.McLean of disability. 54(3). a belief in other forms of alternative treatment unique to Indian culture. (1)(1). 475-487. ©2010. specific exercise on chronic low back pain: A controlled study of 895 consecutive patients with 1-year follow up. Archives of physical medicine and rehabilitation. Biological psychiatry. 47-53. Lip GY et al (1996) Ethnic differences in public health awareness.Horabin. 12(2). Marwaha. Manual therapy. Friedrich M et al (1998) Combined exercise and motivation program: Effect on the compliance and level of disability of patients with chronic low back pain: A randomized controlled trial. Kolt GS et al (2007) The sport injury rehabilitation adherence scale: A reliable scale for use in clinical physiotherapy. Nelson BW et al (1995) The clinical effects of intensive. 93(1). 17-22. S. Cochrane database of systematic reviews. 86-94. 15(3). were not identified indicating that physiotherapists may not be aware of all the potential barriers which may prevent patients from adhering with treatment recommendations. Ethnicity & health. Journal of rehabilitation medicine. Orthopedics. Clinical journal of pain. Journal of the national medical association. Medina-Mirapeix F et al (2009) Personal characteristics influencing patients' adherence to home exercise during chronic pain: A qualitative study. Pan american journal of public health. 347-352. 25(1). Burnett A et al (2009) A cross-cultural study of the back pain beliefs of female undergraduate healthcare students. Post DM et al (2001) Teaching patients to communicate with physicians: The impact of race. 93(1). 79(5). anxiety or low levels of activity.M. Journal of epidemiology and community health. 1(1).Indian physiotherapists’ perceptions of factors that influence the adherence physiotherapy treatment K. Physiotherapy. 6-12. 41(5). Journal of occupational medicine. health perceptions and physical exercise: Implications for heart disease prevention. 31(6). However many psychological and sociodemographic factors e. 399-409. International Journal of Physiotherapy and Rehabilitation 17 . References Alexandre NM et al (2002) Predictors of compliance with short-term treatment among patients with back pain. CD000963. Guzman J et al (2002) Multidisciplinary bio-psycho-social rehabilitation for chronic low back pain. 547550. 132-138. Campbell LC et al (2003) Persistent pain and depression: A biopsychosocial perspective. Reilly K et al (1989) Differences between a supervised and independent strength and conditioning program with chronic low back syndromes. 971-981. Jack K et al (2010) Barriers to treatment adherence in physiotherapy outpatient clinics: A systematic review. 55(2). 20-28. Campbell R et al (2001) Why don't patients do their exercises? Understanding non-compliance with physiotherapy in patients with osteoarthritis of the knee. 18(10).g. H.

2359-66. Physical therapy. Medicine and science in sports and exercise. Public money and management.M.Indian physiotherapists’ perceptions of factors that influence the adherence physiotherapy treatment K. 2784-2796. 771-82. ©2010. 977-985. International Journal of Physiotherapy and Rehabilitation 18 .evidence for action. Rushmer R and Pallis G (2003) Inter-professional working: The wisdom of integrated working and the disaster of blurred boundaries.Horabin. Marwaha. 76575-578. van Tulder M et al (2000) Exercise therapy for low back pain: A systematic review within the framework of the cochrane collaboration back review group. Spine. S.McLean Rejeski WJ et al (1997) Compliance to exercise therapy in older participants with knee osteoarthritis: Implications for treating disability. Sluijs EM et al (1993) Correlates of exercise compliance in physical therapy. 25(21). Vasey L(1990) DNAs and DNCTs . 73(11). WHO (2003) Adherence to long term therapies . 29(8). Geneva. World Health Organisation. H.why do patients fail to begin or complete a course of physiotherapy treatment? Physiotherapy.