Barriers and facilitators for strengthening physiotherapy services in Nepal: perspectives from physiotherapists and health providers

Abstract

Background: Physiotherapy provides non-invasive and non-pharmaceutical intervention for curative, rehabilitation and preventative purposes. Physiotherapy is also a central provider of health promotion. As the global burden of non-communicable diseases and chronic health conditions is rising, the importance of physiotherapy services increases. Unfortunately, physiotherapy services in low- and middle-income countries (LMICs) are generally unsatisfactory. In Nepal, the earthquake in 2015 and the COVID pandemic have clearly illuminated the importance of physiotherapy.

Objective: This qualitative study aimed to identify barriers and facilitators at different system levels for strengthening physiotherapy services in Nepal.

Methods: Forty semi-structured individual interviews were performed with different health providers. Transcribed interviews were assessed with thematic analysis. A five-level socioecological framework conceptualised multilevel determinants of barriers and facilitators.

Results: The study revealed various factors that were potential barriers and facilitators across five different levels, namely individual (taking the lead, need for advocacy), interpersonal (lack of recognition and autonomy, networking for referrals and coordination), community (lack of knowledge and awareness, social and family support), organisational (accessibility, workplace and clinical practice, educational opportunities, role of organisations and rehabilitation centres), and public policy level (planning and implementation of policies and programs, medical hegemony, priorities). Government officials, local leaders, and clinicians, half of whom were physiotherapists, agreed on many of the same issues, where a lack of awareness of what physiotherapy is and knowledge about what physiotherapists do was central.

Conclusions: The results provide information for the development of physiotherapy by pointing out key elements that need attention. Our broad and structured investigation strategy is applicable to others for a comprehensive analysis of barriers and facilitators for physiotherapy services.

Keywords: Chronic diseases, Socio-ecological model; Disability; Health system; Non-communicable disease.

Fig. 1

Recruitment procedure of informants

Fig. 2

Socioecological framework for factors affecting physiotherapy services in Nepal. We used the socioecological concept [33] and constructed a five-level bubble diagram which we populated with categories under the themes derived from our interviews. The figure was redrawn using data acquired from different sources to guide the research. Factors included in the original model by McLeroy et al. Ecological perspective on health promotion programs, 1988. P355: Individual - Attitude, behaviour, knowledge, perception, self-concept, skills; Interpersonal - Formal social network and support system, Work group network, Friendship network; Community - Informal network within defined boundaries, Personal friendship network, Neighbourhoods; Organisational - Institutions with organisational characteristics and formal (and informal) rules and regulations for operation; Public policy - Local/State/National legislatures. Note: Barriers and facilitators for development of physiotherapy defined under different categories using thematic analyses were placed into the different levels in the socioecological framework based on contextual relation and significance to the Nepalese physiotherapy system or physiotherapy in general