Keywords
Musculoskeletal disorder, musculoskeletal physiotherapy, service quality evaluation, Tigray, Ethiopia
This article is included in the Health Services gateway.
The provision of effective musculoskeletal physiotherapy and treatment outcomes are challenged by the shortage of resources, limitations in adherence to clinical guidelines, and client unacceptability. This study aims to evaluate the process quality of musculoskeletal physiotherapy service in the physiotherapy department of Ayder Comprehensive Specialized Hospital, Mekelle, Ethiopia, 2020.
This is a health facility-based single-embedded case study design that involves both quantitative and qualitative methods to describe the service using a three dimensions assessment for quality service evaluation (compliance of the unit, technical compliance, and service acceptability). The quantitative data was collected through document review and observation of the musculoskeletal physiotherapy unit, direct observations of 20 client-physiotherapist interactions, and chart review on systematically selected 172 client charts. For qualitative data; in-depth interviews with five Key informants and 21 clients were conducted. The interviews were audio recorded, transcribed, translated, and analyzed thematically. The data were entered into Epi-Data version 3.1 and exported to SPSS v.25 for analysis. Descriptive statistics was done and data were presented using frequency and percentage. The calculated outputs were used to judge the overall service against the predetermined criteria (i.e. Excellent, Very Good, Good, Fair, and Poor).
The compliance of the musculoskeletal physiotherapy unit, service providers’ technical compliance, and service acceptability by the users were judged poor (56.1%), fair (60.1%), and good (73.1%) respectively. The compliance of physiotherapists in recording patient information was concerningly poor (30.2%). The majority of clients were satisfied with the service and adhered to their treatment.
The overall service process quality of physiotherapy service was judged as fair (62.55%). However, the assessed dimensions were not as per the expected standard. Therefore, the relevant stakeholders are recommended to improve the service provision gaps.
Musculoskeletal disorder, musculoskeletal physiotherapy, service quality evaluation, Tigray, Ethiopia
• The compliance of the musculoskeletal physiotherapy unit and service providers’ technical compliance were judged as poor (56.1%) and fair respectively.
• The main constraints to the availability of resources were overlapping of duty, failure to repair damage to equipment and budget shortage.
• The service acceptability by the users were judged as good (73.1%).
• The physiotherapists were complied with the standard guidelines while taking history and conducting physical examinations, however they were less compliant in recording patient information.
• The majority of clients were satisfied with the service and adhered to their treatment.
• The perceived wellness, the absence of caregivers to assist patients, work-related commitments, and concerns about the financial burden of treatment were the identified threats for the difficulty of adhering to treatment follow-up schedules.
Musculoskeletal disorders, which include conditions that affect bones, joints, muscles, and other body systems, are the leading source of pain and disability globaly.1–3 According to a recent review by the Global Burden of Disease (GBD), 1.71 billion people worldwide suffer from musculoskeletal disorders.4 The burden of musculoskeletal disorders in the developing world increased by 60% from 1990 to 2010.5 MSD’s are the second most common cause of years lost to disability in sub-Saharan.6 A recent study conducted in northwest Ethiopia shows the the overall prevalence of musculoskeletal disorders among the population was 40.1%.7 To overcome these burdens, musculoskeletal physiotherapy intervention were found to be most effective in treating various conditions related to musculoskeletal disorder8–10
Musculoskeletal physiotherapy (MsPT) is a service given to patients who are exhibiting the symptoms of musculoskeletal disorder to help them recover from their condition more quickly.3,11,12 It involves the interaction between a physiotherapist, patients, and care givers in a process of assessing movement potential and establishing agreed upon goals.12–14
Provision of quality musculoskeletal physiotherapy service necessitates assessment, planning, implementation, and evaluation of treatment outcomes for the client’s condition, which are based on sound clinical reasoning, diagnosis, and evidence-based practice.15–17 However, research’s indicated that the provision and quality of MsPT services are challenged by several factors, including inadequate health workers and a lack of equipment and supplies.18–20 Likewise, the way in which the facility and the resources are organized to serve clients and evidence-based practice of physiotherapists have greatly impacted the quality and treatment outcomes of MsPT service.21 These results in hindering the provision of timely and complete treatment or inappropriate treatment, suboptimal patient outcomes and wasted resources. In addition, as a result of service unacceptability by clients, clients are having the worst outcomes as they miss more appointments, leave against advice, or fail to follow treatment plans.3,22
To address those MsPT service delivery challenges, nations have launched different initiatives so far. Ethiopia, in 2010, has adopted relevant initiatives in order to address the needs of people with disabilities, including quality health service.15 Also, the nation has been implementing the National Health Care Quality Strategy, which is focused on ensuring that protocols around quality are reliably implemented, building off the extensive resources and infrastructure that the government has already put in place.23,24
Inspite of those efforts, studies showed that unavailability of resources for physiotherapy service implementation and difficulty of physiotherapists in introducing clinical guidelines into their routine practice remains challenges in provision and quality of MsPT service.25 As a result, MsPT service remain too focused within secondary care and have not kept pace with improvements in community-based rehabilitation.26
In Ethiopia, the most important challenges in the practice of physiotherapy were discouraging working environment, lack of medical equipment for the quality care, and most importantly lack of evidence-based practice.26 Therefore, this evaluation study aims at assessing the process of MsPT service delivery. In addition, by identifying and improving the gaps or weakest points of the service the results and recommendations generated from this study will provide information for decision making on MsPT service process improvement.
The study was conducted from February 16 up to March 30, 2020, in Ayder Comprehensive Specialized Hospital (ACSH), which is located in Mekelle city, the capital city of Tigray regional state of Ethiopia. The city is located 783 km away north of Addis Ababa, the capital city of Ethiopia, and has a total population of 587,000.27 Out of the total ten public health centers and four public hospitals, ACSH is the only one that provide musculoskeletal physiotherapy service. It is rendering its referral and non-referral services to the 8 million populations in its catchment areas of the Tigray, Afar and Northeastern parts of the Amhara Regional States, including the Eritrean refugees, since 2008.28
Purposively selected, health care providers (physiotherapists), MsPT service coordinators, and patients were the study participants. In addition, registration books, patient medical records, and the human, physical and material resources of the unit, including the MsPT unit itself, were used to gather information for this evaluation analysis.
Full time physiotherapist, physiotherapy head and service coordinators, who have been serving at least for six months in the clinic, and MsPT patients who were on follow up in the study unit were included in the evaluation. Besides, the clinical records of patients who get service in MsPT unit in the last 6 months prior to the data collection period were included.
This evaluation is to gain and interpret useful information that can assist service improvement. The evaluation was also fully participatory to service stakeholders, which increase evaluation credibility and maximize utilization of evaluation findings. Therefore, this evaluation used formative evaluation approach to obtain concrete information concerning the operation of the musculoskeletal physiotherapy service.29
The focus of the evaluation is on the process of musculoskeletal physiotherapy service delivery, which aims to clearly understand the internal dynamics of the service operations as it can help in identifying areas where improvements might be made.
The design used for this evaluation was health facility based single embedded case study design which involved both quantitative and qualitative methods to describe the service using variety of reliable information.30 The information obtained through this method relies on multiple sources of evidence, with data needing to converge in a triangulating fashion and helps to ensure trustworthiness.31
The first dimension was compliance of the MsPT unit with the national physical rehabilitation service implementation standard, and under this dimension, the availability and accommodation components of access are evaluated. The aavailability sub-dimension assesses the presence of the necessary inputs to carry out the MsPT service. The accommodation sub-dimension measures the way that musculoskeletal physiotherapy service organized to accommodate clients including the treatment room, waiting area, and external physical environment of the unit.
The second dimension employed for this study was technical compliance of the MsPT service providers to the national physical rehabilitation standard in providing MsPT services to patients. The compliance dimension assesses whether physiotherapists are diagnosing, conducting physical examination, following up and recording complete information of patients according to the recommended national physical rehabilitation guideline. Therefore, the activities of musculoskeletal physiotherapists were assessed and compared with the standard.
The third dimension used to judge the service delivery of the MsPT unit was acceptability of the service by its users.
Quantitative
We used different source for the different dimensions of the evaluation.
Availability: All the service documents in unit were assessed through a structured checklist format to evaluate resource availability. In addition, physical count was made to estimate proportion of the unit’s patient load with the required human resources.
Accommodation: To assess the way in which the health facilities and the resources are organized according to the standard, direct observation technique was applied. Treatment room setup, waiting area setup, and physical environment setup for safe access were addressed.
Technical compliance: To determine the compliance of health professionals’ performance direct non-participatory observation was conducted on forty client provider interaction. In addition, to investigate if the patients were assessed for MsPT treatment follow-up adherence we retrospectively reviewed the clients medical card using systematic random sampling. The sample size was calculated at the maximum allowable error of 5% and population proportion of 79.7 % from a previous study on physiotherapy documentation of patients’ record.32 Thus, the calculated sample size was 156 clinical records of patients. However, to accommodate possible missing of the clinical records 10% of the calculated sample was added. Altogether, the sample size established at 172 clinical records. The total patients who were registered and using the service in the unit, six months prior to the data collection time were 486. Thus, the sampling interval (K) was calculated to be three. Among total one hundred seventy-two reviewed client medical records 100 (58.1%) were male client records. The age of clients ranges from 18-74, with a mean age of 46.32(SD ± 14.03) (Table 1, Participant characteristic, Physiotherapist recording compliance, Extended data, https://doi.org/10.7910/DVN/RE3EUL).
Acceptability: Exit interview were done on randomly selected 15 clients who were on reassessment to see whether they are satisfied on their visit in MsPT unit. To determine the level of clients’ adherence, the 172 clients’ adherence assessment sheets were reviewed.
Qualitative
For qualitative data in-depth interview was conducted with purposively selected Key informants who are information rich. Finally, five key-informant; one head of physiotherapy, one MsPT unit clinical coordinator, and three physiotherapists’ staffs from the MsPT unit were interviewed. Additionally, in-depth interview was done on 21 clients who were under MsPT treatment during the data collection period. The data was collected until the information was saturated.
Checklists were used for resource inventory, service setup adequacy, patients’ record review, and care providers’ technical compliance observation. The checklists consist of important indicators to examine the availability of important resources, the accommodation level of the unit, and whether the patients are appropriately diagnosed, physically examined and their medical information recorded according to the national physical rehabilitation service implementation standard (Annex C, D & E, Extended data, https://doi.org/10.7910/DVN/RE3EUL).
Exit interview by structured questionnaire was done with clients to determine their level satisfaction by their health care experience during visit in MsPT unit. To assure tools validity and reliability, questionnaire is adapted from “A brief questionnaire for assessing patient healthcare experience in low-income settings33 (Annex F, Extended data, https://doi.org/10.7910/DVN/RE3EUL).
Interview Guide: Interview guide was used to collect qualitative data from service coordinators, health care providers, and patients. In addition, field notebook & audio were used recorder documented information (Annex G & H, Extended data, https://doi.org/10.7910/DVN/RE3EUL).
To minimize observation bias the data collectors were recruited from other health facilities. The principal investigator undertook key informant interviews after the quantitative data collection was completed.
Quality control measures were undertaken to enhance the credibility and trustworthiness of the outcomes of the evaluation. The checklist for data collection was pretested on 10% of the total sample size at Mekelle hospital physiotherapy unit prior to actual data collection for checking the validity and consistency record completeness.
Quantitative
The quantitative data were cleaned for completeness and entered to Epi Data version 4.03 and exported to Statistical Package for Social Science (SPSS) version 25.0 for analysis (IBM Corp., Armonk, NY). For readers seeking an open-source alternative, equivalent analyses can be performed using JASP (https://jasp-stats.org/) or R (https://www.r-project.org/). Descriptive statistics was done and data were presented using frequency and percentage. Microsoft Excel was used to compute the evaluation of data obtained by observation. The calculated outputs were used to judge the overall service against the predetermined criteria (i.e. Excellent, Very Good, Good, Fair and Poor).
The qualitative data was collected and audio-recorded and later transcribed by two investigators separately and translated into English. After comparing each translation and checking the consistency, the data was entered, coded and analyzed by three coauthors using open code version 4.03, open source (available at: https://www.umu.se/en/department-of-epidemiology-and-global-health/research/open-code2/).34 Thematic analysis approach was employed to interpret the data. First, descriptions and specific ideas were coded separately, inter-related or similar codes were then grouped into different categories, and the categories were subsequently clustered into specific themes. Participant quotes were used to emphasize or support emerging themes in the result presentation (Table 2, Extended data, https://doi.org/10.7910/DVN/RE3EUL). Both the quantitative and qualitative findings were triangulated and presented together.
Musculoskeletal Physiotherapy (MsPT): Refers to an area of physiotherapy which deals with patients with musculoskeletal condition.12
Process quality: In this evaluation, process quality defines as the alignment of MsPT unit and compliance of health care providers according to the 2018 national Rehabilitation guideline and service acceptability by the users.12 When these three dimensions’ minimum requirements fulfilled, the service will have good process quality.
Evaluation dimension: Important aspects of the service to be explored during the evaluation.
Availability: Means the presence and adequacy of both human and material resources of MsPT unit to deliver proper MsPT services to patients. Judged If >90 excellent, (80-90] very good, (70-80] good, [60-70] fair and <60 poor.
Accommodation: In this evaluation accommodation mainly refers to the adequacy musculoskeletal physiotherapy service setup to accommodate clients including the treatment room, waiting area, and external physical environment of the unit for safe access. Judged If >90 excellent, (80-90] very good, (70-80] good, [60-70] fair and <60 poor.
Technical compliance: Means the process of health care providers (physiotherapists) taking history, conducting physical examination and recording medical and follow-up information of patients at the outpatient musculoskeletal physiotherapy service according to national guideline. Judged If >90 excellent, (80-90] very good, (70-80] good, [60-70] fair and <60 poor.
Acceptability: In this evaluation we consider the service is acceptable by users when clients are satisfied by their health care experience during their visit in MsPT unit and adhere at their treatment follow-up appointments. Judged If >90 excellent, (80-90] very good, (70-80] good, [60-70] fair and <60 poor.
Adherence: The concept of adherence relates to attendance at treatment follow-up appointment.
For further clarity and understanding all indicators are operationalized at table 3 (Table 3, Extended data, https://doi.org/10.7910/DVN/RE3EUL )
For each dimension and indicator different guidelines and literatures were referred to assign the weight.12 After discussion & agreement with stakeholders, the final agreed weight was re-adjusted and given. The final evaluation judgment of the service was decided based on the criteria listed in Table 4 and Table 5, and the result were presented in tables ( Tables 6, 7, 8, 9 & 10).
The study was conducted in adherence to the ethical principles outlined in the Declaration of Helsinki for research on human participant.35 Ethical approval to conduct the study was obtained from Mekelle University, Institutional Review Board (IRB) in March 15, 2020 G. C, with approval number IRB001. A support letter was subsequently issued by the university’s Research and Development Office to the Ayder Comprehensive Specialized Hospital’s physiotherapy department. Written informed consent was obtained from the head of the unit for the MsPT unit observation and chart review.
All participants were provided with comprehensive information regarding the study’s objectives and its importance for program improvement. Written informed consent was obtained from each participant, ensuring their understanding and voluntary agreement to partake in the research. Confidentiality was strictly maintained, and no unique identifiers were collected to ensure anonymity. Additionally, no compensation or reimbursement was provided to participants for their involvement. Full supporting documentation, including consent forms and the study protocol, can be found in the extended data (Annexes A and B, https://doi.org/10.7910/DVN/RE3EUL).
Availability of resources: The compliance of the MsPT unit to the national physical rehabilitation service implementation standard was assessed based on the availability of various resources. The findings revealed that the overall evaluation of the availability dimension was rated poor (53.7%).
Availability of human resource: There was a shortage of five physiotherapists in the unit, as the current patient flow requires ten physiotherapists per shift. As a result, the unit was rated as ‘poor’ (50%) in ensuring the availability of licensed physiotherapists to deliver MsPT services ( Table 6).
According to key informant’s report, the shortage was due to physiotherapists being assigned to other duties, such as lecturing, and clients not adhering to follow-up schedules. This was best described by one physiotherapist (citation #1, Table 2).
Availability of premises: In MsPT unit, out of the fourteen required physical infrastructures, only nine were available, leading to a ‘fair’ rating (64.3%) for the availability of needed premises as per the service standard ( Table 6).
Availability of guidelines: During this evaluation, one manual of the 2018 FDRE Ministry of Health Physical Rehabilitation Service Guideline was available in the MsPT unit, which resulted in an ‘excellent’ rating (100%) for the availability of the service guideline ( Table 6).
Availability of clinical assessment tools: The study also revealed that only eight clinical assessment tools were available in the MsPT unit, with some key tools, such as the weight scale (which was non-functional), hand-held dynamometer, pinch gauge, inclinometer, megatoscope, floor scale, and spirometer, either missing or non-functional. Informants confirmed the unavailability of these tools before the evaluation. Consequently, the unit was rated ‘poor’ (53.3%) for the availability of the necessary clinical assessment tools ( Table 6).
Availability of therapeutic exercise equipment: The study identified a lack of essential therapeutic exercise equipment, including therapy putty, squeeze balls, power web, adjustable wrist and ankle weights, dumbbells, and other critical items. As a result, the MsPT unit was judged ‘poor’ (44.4%) for its compliance with the standard in fulfilling the necessary therapeutic exercise equipment ( Table 6).
The qualitative finding shows that the shortage of clinical assessment and therapeutic exercise equipment was primarily due to delays in purchasing new items and the unavailability of spare parts for damaged equipment. A physiotherapist with 14 years of experience emphasized this challenge (citation #2, Table 2). Similarly, another key informant states that budget shortage was the main challenge to avail the basic resources to the physiotherapy service (citation #3, Table 2).
We have asked physiotherapists what they do when they experience shortage of materials for patient examination or treatment. Accordingly, all the interviewed responded that, they customize already available materials in the unit to suit the individual requirements (citation #4, Table 2).
Accommodation of the service: The overall evaluation of the accommodation subdimension of the Compliance of the MsPT unit to the national physical rehabilitation service implementation standard was rated poor with 53.3% overall observed score. The evaluation of each component of the accommodation dimension is as bellow.
Adequacy of treatment room setup of MsPT unit: Direct observation with a standard checklist confirmed that only 55.6% of the treatment room setup in MsPT was in agreement with the standard. Out of the expected MsPT treatment delivery room setup to accommodate MsPT service clients only five of them were fulfilled. The most important components of the standard which are missed in the unit were the lack of private room for patients to change closing before and after treatment, separate wash room with bath room facility, functional running water in disabled accessible location, and ability of the unit to maintain visual privacy of clients. As a result, the adequacy of the treatment room setup in MsPT unit is rated ‘poor’ ( Table 7). This was also supported by the qualitative finding as stated by one patient with slipped disk (citation #5, Table 12).
Adequacy of waiting area setup of MsPT unit: The study findings revealed that out of the eight considered necessary components of waiting area setup only half is available in MsPT unit. Lack of adequate number of sits per patient per day, guide, audiovisual corner with TV for educating patients and their families, and supporting devices such as wheelchairs and stretchers are the most important components which were missed. Consequently, the adequacy of the waiting area setup in MsPT unit is rated ‘poor’ (50%) ( Table 7). The findings regarding the inadequacy of the waiting area setup of the MsPT unit was also supported by the clients’ report in the qualitative interview (citation #6, Table 2).
Adequacy of the physical environment setup of MsPT unit (for safe access): The adequacy of the physical environment setup of MsPT unit for safe access of patients to the facility is rated ‘poor’ (50%) due to the absence of disabled accessible parking and smooth pavement pathway in the unit ( Table 7). This compromises the safe access of disabled clients to the unit (citation #7, Table 2).
The treatment room, waiting area, and physical environment setups in the MsPT unit was also below the recommended (citation #8, Table 2). The main reason for the existence of MsPT unit setups below the standard was the lack of budget, as described key informant (citation #9, Table 2).
Direct non-participatory observation was conducted on forty client provider interaction (two providers with 20 clients each) to assess the compliance of MsPT service providers. Accordingly, the physiotherapists’ practice in appropriate clients’ history taking, physical examination and recording compliance is rated ‘fair’ (65%), excellent’ (100%) and poor’ (30.2%) respectively ( Table 8).
According to the qualitative study the main reason for lack of consistency in complying with guideline while taking history and documenting clients’ information was patient load (citation #10, 11, Table 2). Moreover, patients’ treatment follow-up assessment sheet was examined to investigate if the patients were assessed for MsPT treatment follow-up adherence. Accordingly, out of the 172 records 78 (45.3%) were assessed and 94(54.7%) not assessed. Thus, the providers’ practice in assessing the patients for their MsPT treatment follow-up adherence, during their follow-up schedule rests on 45.3% which is ‘poor’ ( Table 8).
The satisfaction of clients with their health care experience during their visit in MsPT unit was rated ‘good’ 73.3%(11 out of 15) ( Table 9). The courtesy of physiotherapists in answering their questions, listening to their concerns, and clearly explaining treatment procedures along with their inclination to give advice to patients, were mentioned by clients as a source of satisfaction in their health care experience during their visit in MsPT unit (citation #12, 13, Table 2).
In contrast, the incongruity of number of patients with the number of health care provider in the MsPT unit, which resulted in inconsistency of time spent with care providers were mentioned by clients as a source of dissatisfaction in their health care experience during their visit in MsPT unit (citation #14, Table 2).
Providers’ attitude towards the MsPT service: We have asked physiotherapists how interested they are in providing MsPT service. Accordingly, they described that the patients recovery is their main source of satisfaction while absence of clear payment guideline and shortage of human resource were mentioned as main source of physiotherapists’ unhappiness while providing MsPT services (citation #15, 16, Table 2).
Provider-client relation: We have asked physiotherapists and key informants about the provider-client relation in MsPT unit. Key informants and health care providers mentioned the existence of a well-built provider-client relation. Even when problems arise, attempts will be made to solve problems on spot or bring issues to the department level to discus and take institutional measures (citation #17, 18, Table 2).
Clients’ adherence to treatment follow-up schedules: Review of patients’ treatment follow-up adherence assessment form indicated that out of the 78 client records assessed for adherence 57(73%) were adherent to the recorded schedules which is rated as ‘good’ ( Table 9). The minimum delay was one treatment follow-up session and the maximum was six treatment follow-up sessions.
Regarding the reason for lack of treatment follow up, unstructured interview was held with six MsPT patients to explore reasons that threaten their treatment follow-up adherence. The reasons reported by patients were: perceived wellness, lack of care giver, having work to do, and feeling of shame of losing one’s money (citation #19, 20, 21, 22, Table 2). Overall service judgment
The overall process quality of MsPT service was judged USING 14 selected indicators in three dimensions: observed compliance within the MsPT unit, technical compliance of physiotherapists, and acceptability. Results indicated that compliance levels were rated as poor (56.1%) for unit compliance, fair (69.1%) for technical compliance, and good (73.1%) for acceptability (Table 10, Extended data, https://doi.org/10.7910/DVN/RE3EUL). Accordingly, based on the weighted scores agreed upon by stakeholders and the observed evaluation results, the overall quality of the service process was classified as fair.
This evaluation assessed the MsPT unit service delivery at Ayder Comprehensive Specialized Hospital based on predetermined judgment criteria. The overall service delivery was rated as ‘fair’ (62.5%), reflecting moderate performance across key evaluation dimensions. A comparative study indicated that, of the 94% of standards assessed, only 36% were met for compliance with standards of practice in health-related rehabilitation in low- and middle-income settings, with 46% showing some issues and 11% facing critical issues.36
The unit’s compliance to standards was found to be ‘poor’ (56.1%), highlighting significant gaps in adherence to guidelines. However, technical compliance by providers was rated ‘fair’ (69.1%), and the acceptability of services by patients was judged as ‘good’ (73.1%), indicating a relatively positive patient-provider interaction.
Resource availability within the MsPT unit was judged ‘poor’ (57.3%), a finding mainly attributed to a shortage of physiotherapists. The evaluation identified a deficit of five physiotherapists, compared to the expected standard, which requires one physiotherapist for every six patients, with each session lasting 45 minutes.12 Key informants suggested that the shortfall was due to high patient load, coupled with physiotherapists being reassigned to other duties, and patients’ inability to adhere to follow-up schedules. This staffing shortage affects the delivery of quality care, as providers struggle to maintain the recommended level of individualized attention.
Physical infrastructure also fell short of standards,12 with only 64% of the required elements in place, which was rated ‘fair’. Furthermore, only 44.4% of the recommended therapeutic equipment was available, which undermines the unit’s capacity to provide complete and timely treatment. This result aligns with findings from a similar study in Chile, where users reported dissatisfaction due to inadequate therapeutic tools.37 The lack of essential equipment not only delays care but also diminishes the perceived quality of services musculoskeletal physiotherapy service, leading to patient dissatisfaction.38 Key informants highlighted that budgetary constraints and delays in repairing damaged equipment were the primary reasons for the unit’s substandard physical infrastructure and equipment.
The accommodation aspect of the MsPT unit was also assessed as ‘poor,’ with only 55.6% of the necessary treatment room setups meeting the standard.12 This mirrors the findings of a study conducted in Sweden, where patients expressed concerns about a lack of visual privacy and discomfort when moving between rooms.39 In the MsPT unit, both the waiting area and the physical environment were rated as ‘poor,’ further emphasizing the inadequacy of the unit’s setup for safe access and patient comfort. The adequacy of the physical environment setup of MsPT unit for safe access of disabled patients to the facility is rated ‘poor’ (50%). Similar finding was reported in study conducted in Nepal where, accessibility for persons with disabilities was reported as partial by 79% of the health facilities providing rehabilitation services.40 Budget limitations were again cited as the main barrier to improving the physical environment and facilities.
Compliance with standards for physiotherapy practice plays a crucial role in ensuring the quality of services.41,42 In this evaluation, technical compliance was rated as ‘fair’ (69.1%), which is comparable with an observational prospective cohort study conducted in Netherland which reported an overall 67.2% adherence of physiotherapist to Clinical Practice Guidelines for Low Back Pain in Physical Therapy.43 However, the recording standards compliance was concerningly poor (30.2%), which are crucial for documenting patient information comprehensively. Healthcare providers reported that they were forced to prioritize tasks due to heavy workloads, which affected their ability to comply fully with the standards. This rate is markedly lower than what was reported in the above study where 60.5%. of healthcare providers compliance were observed in history taking.43 The main reason for this low compliance was the insufficient number of physiotherapists relative to patient volume, making it challenging to gather and document complete patient histories. Key informants noted that physiotherapists were only recording information deemed essential for immediate treatment, rather than adhering strictly to standard record-keeping protocols.
The acceptability of the MsPT unit’s services from the patients’ perspective was rated as ‘good’ (72.6%). Patients expressed satisfaction with their interactions with physiotherapists, particularly in terms of the courtesy shown by staff, the clarity of explanations regarding treatment procedures, and the willingness of providers to answer questions. This is finding is high compared to previous study done in Amhara region, Ethiopia where the overall satisfaction among physiotherapy outpatient attendee was 50.1%.44 However, the limited time therapists spent with patients due to the high workload was a source of dissatisfaction for some patients. Despite this, adherence to treatment follow-up schedules was relatively high, with 73.1% of patients attending their appointments. The adherence rate was markedly higher than a previous study conducted in Nigeria, where only 24.5% of patients where adherent to their home exercise treatment program.45 This discrepancy might be due to the difference in the treatment program, where in this study we assessed treatment adherence to hospital follow up while in the previous study only for home exercise program. Additionally, it might be due to the relatively high satisfaction of patients with the physiotherapist care and approach in the current study. This highlights the critical role of a strong provider-patient relationship in ensuring adherence to treatment.
Several factors were identified as key reasons that influenced patients’ ability to adhere to their follow-up schedules. These factors include perceived wellness, the absence of caregivers to assist patients, work-related commitments, and concerns about the financial burden of treatment. These findings are consistent with those reported in other studies, though the context and methods of evaluation differ.45,46 These factors highlight the multifaceted nature of patient adherence, which is influenced by individual, provider, and organizational elements.
The overall process quality of MsPT service at Ayder Comprehensive Specialized Hospital demonstrates moderate performance in service delivery. However, significant gaps remain in compliance with standards, resource availability, and infrastructure. Addressing these issues, particularly the shortage of physiotherapists and the lack of necessary equipment, is essential to improving the overall quality of care. Despite these challenges, improving the technical compliance of healthcare providers and further enhancing service acceptability by clients could potentially elevate the overall quality of MsPT services beyond the current ‘fair’ rating, even with the existing human and material resources.
The evaluation included both qualitative, quantitative methods, and the study-maintained interest of stakeholders by incorporating their opinion to give relevant information for decision-making and to increase information use. However, due to the Covid-19 pandemic, the communication with the stakeholders was not regular and was limited. Moreover, during health care provider’s observation, even though an attempt was made to minimize the hawthorn effect, the magnitude of hawthorn effect was not assessed. Hindering and facilitating measured effect of the MsPT service towards other physiotherapy services in the physiotherapy department weren’t included in this evaluation study.
Ethical approval to conduct the study was obtained from Mekelle University, Institutional Review Board (IRB) in March 15, 2020 G. C, with approval number IRB001.
Written informed consent was obtained from each participant, ensuring their understanding and voluntary agreement to partake in the research.
MWA, TH & TS: conceptualization, data curation, formal analysis; HKM & STY: methodology, supervision and validation, writing – original draft; MWA, TH, AA & EM: writing – original draft & writing - review & editing.
All the data sets and audio recordings are available on reasonable request to the corresponding author and if approved by the Institutional Review Board of Mekele University. To protect the privacy of the respondents the data couldn’t be publicly shared, because some of the audio recordings can’t be completely de-identified and we haven’t got permission from the ethical approval body for publically sharing the data set. For all other detail data sets, an extended data is available at online repository.
This dataset contains the data for the study titled “Evaluation of musculoskeletal physiotherapy service quality in Ayder Comprehensive Specialized Hospital, Tigray, North Ethiopia” In this repository; we include the information sheet, detail consent form and the data collection tools and evaluation form together with result of the evaluation collected from the patient’s record, observation of the musculoskeletal physiotherapy unit and interview with the patients and physiotherapist.
Harvard Dataverse: Dataset for the Study”Evaluation of musculoskeletal physiotherapy service quality in Ayder Comprehensive Specialized Hospital, Tigray, North Ethiopia - Mulugeta Arage Dataverse (https://doi.org/10.7910/DVN/RE3EUL).47
The extended data set contains the following data:
• Participant information sheet and consent form
• Data collection tool and interview guide
• Table 1. docx
• Table 2. docx
• Table 3. Docx
• Table 10. docx
• Participant characteristic data set.
• Physiotherapist recording compliance data set
Data are available under the terms of the Creative Commons Zero “No rights reserved” data waiver (CC0 1.0 Public domain dedication).
The quantitative data analysis was conducted using SPSS version 25.0 (IBM Corp., Armonk, NY). For readers seeking an open-source alternative, equivalent analyses can be performed using JASP (https://jasp-stats.org/) or R (https://www.r-project.org/). The qualitative data was analyzed using Open Code 4.03 software, for which open source available at (https://www.umu.se/en/department-of-epidemiology-and-global-health/research/open-code2/).34
The authors would like to acknowledge the Ayder Comprehensive Specialized Hospital, the physiotherapy department for their support during data collection, and the study participants for their active participation in this study.
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