Level of satisfaction regarding physical therapy services in district Poonch, Azad Jammu Kashmir

Objective: To determine the patients' satisfaction level regarding physical therapy services at district-level hospitals. Method: The cross-sectional study was conducted at tertiary hospitals of Poonch district in Azad Jammu and Kashmir from January to June 2018, and comprised patients of either gender aged 15-70 years receiving physical therapy treatment. A semi-structured questionnaire was used to collect data regarding patients' satisfaction from physiotherapy services.. The demographics were recorded and standardised assessment tools used included Short-Form Patient Satisfaction Questionnaire and Medrisk instrument for measuring patient satisfaction. Data was analysed using SPSS 22. Results: Of the 392 subjects, 209(53%) were males and 183(47%) were females, with an overall mean age of 39.7±12.6 years. The response regarding satisfaction was positive in 376(95.85%) cases and negative in 16(4.15%) cases (p<0.05). Conclusion: There was a high level of satisfaction regarding physiotherapy services in the studied area.


Introduction
In a healthcare system, physiotherapy is the medical science focussing on the patients' physical condition and treating them. 1 Physiotherapists established a resilient status in the rehabilitation therapy after the Great War in the early part of the 20th century.Physical health and healthy lifestyle is achieved by the help of physiotherapy after any major trauma. 2,3Physiotherapists treat people of every age undergoing any kind of disorder, like back pain, cystic fibrosis, knee pain, shoulder problems, stroke, neurodegenerative diseases, spinal cord injury, cardiopulmonary diseases, arthritis, sports injuries, cerebral palsy, developmental delay, strains or sprain injuries. 4hysiotherapy helps in reducing pain, improving joint mobility and strength, restoring physical function and preventing injury, preventing or delaying surgery, improving balance, coordination, strength, flexibility and function, and restoring the aptitude to survive daily tasks. 5,6hysiotherapists are educated to evaluate, treat and prevent the physical limitation and dysfunction through exercises, mobilisation and therapeutic techniques.Physiotherapists put their best to help their patients live an independent life. 7In physiotherapy, different methods and modalities are used for treatment, like ultrasound therapy, shortwave diathermy, mobilisation, exercise therapy, traction, electrical nerve stimulation, laser therapy or infrared lamps. 8In Pakistan, physiotherapists are facing great challenges due to competitive marketplace conditions made worse by trend among some physicians to reduce physiotherapy referrals.With increase in marketplace competition, patient satisfaction has emerged as a variable of critical importance.Also, patient satisfaction may identify the likelihood of treatment compliance. 9hen patients are dissatisfied, they can spread a negative message about an organisation, resulting in a heavy loss to that organisation.Patients who report high satisfaction are more likely to continue the relationship with the healthcare practitioners. 1 From a rehabilitation perspective, a study defined patient satisfaction as a "construct reflecting the overall experience of an individual receiving examination and treatment in a given environment during a specific time period". 10Patients satisfaction is an attitude or a person's general orientation towards overall experience of healthcare.The current study was planned to determine the level of satisfaction regarding physiotherapy services available in a predefined region.

Patients and Methods
The cross-sectional study was conducted from January to June 2018 at three tertiary care hospitals -His Highness (HH) Sheikh Khalifa bin Zeyed Al Nahyan Hospital, Taluka Headquarter ( THQ) Hospital, Hajira, and Jamal Physiotherapy Clinic -in district Poonch of Azad Jammu and Kashmir (AJK).
After approval from the ethics committee of Riphah College of Rehabilitation Sciences, Riphah International University, Islamabad, Pakistam, the sample size was calculated using Epitool with 95% Confidence interval (CI). 11Using purposive non-probability technique, the sample was raised with patients of either gender aged 15-70 years who were receiving physical therapy treatment.Those having communication problems and any cognitive impairment were excluded.Informed written consent was obtained from the subjects.A semi-structured questionnaire was used to collect data along with Short-Form Patient Satisfaction Questionnaire (PSQ-18) and Medrisk instrument for measuring patient satisfaction (MRPS).PSQ-18 consists of items such as general satisfaction level, technical quality, interpersonal manner, communication, financial aspects, time spent with doctor, accessibility and convenience.Participants were asked how they felt about the physiotherapy care they were receiving in general, with no specific frame to time and visit.Responses to each item were taken on a 5-point scale from 'strongly agree' to 'strongly disagree' . 12,13PS consists of 10 specific items and 2 global items.Scores for each item were coded from 1 ('strongly disagree') to 5 ('strongly agree').Together, the scores indicated patients' satisfaction level. 14ta was analysed using SPSS 22and expressed as either mean and standard deviation (SD) or as frequencies and percentages.

Results
Of the 392 subjects, 209(53%) were males and 183(47%) were females, with an overall mean age of 39.7±12.6 years.The maximum number of patients had cervical issues 135(34%) followed by lumbar problems 54(14%) (Table 1 MRPS showed highest mean results 4.9±0.1 for the factor of interpersonal relationship between therapists and patients, indicating that the therapists treated their patients with utmost care.Overall, 376 (95.85%) patients were satisfied with the services and said they would return to that particular health facility for future treatment.Only 16 (4.15%)cases expressed their dissatisfaction with the services they were receiving (p<0.05),stressing that the physiotherapists' attitude was too business-like and impersonal (Tables 2-3).

Discussion
Although patient care involves many different aspects, the two most important are the technical and interpersonal.Currently, physiotherapy continues to push for evidence-based practice, and the therapists focus on providing technically improved care.This is vital in advancing the profession, but evidence also indicates that by encouraging patients to take an active role in their healthcare, the effectiveness of their therapeutic activities can be enhanced.In the current study, most of the patients were taking physiotherapy sessions according to their disease pattern and majority were satisfied with the treatment, registration process, therapist-patient interaction, and environment and medical equipment used for treatment purposes.Among those who had showed lack of compliance linked it with financial problems, transport and distance problem etc. as has been reported earlier as well. 15e methods of data collection regarding patient satisfaction have been addressed widely in literature in different regions of the world, but Pakistan lacks such studies. 16,17The current study was the first such effort conducted in tertiary hospitals of AJK which may have inherent bias due to difference in socio-demographics and availability of physiotherapy services.Some studies have advised that patient satisfaction may be related with patient characteristics such as age, gender or educational status. 18However, while multivariate analysis in the current study suggested that patients satisfaction was related with older patients and those with spinal problems.It is possible that other patient characteristics such as mechanism of injury, chronology or clinical outcomes may affect satisfaction level and this is currently being investigated in a randomised controlled trial (RCT) of private and public physiotherapy services for patients with low back pain. 19,20It has been reported that satisfied patients will return for treatment when the need arises, and will speak in satisfactory terms about the treatment and facility. 21,22Thus it is vital that private as well as government hospital physiotherapists make efforts to conform that their patients are satisfied. 23e current study has provided a better understanding of physiotherapy-related satisfaction issues, which, if addressed professionally, encourage more patient satisfaction, and may encourage researchers in other physiotherapy centres of the region to take up similar initiatives 24 and has the potential to assist physiotherapists in making choices regarding professional development and marketing strategies in a manner that may integrate patient feedback. 25Nevertheless further studies with sufficiently large sample sizes are necessary to evaluate the data quality, scale structure, reliability and validity of such efforts.