Satisfaction and adherence of patients with amputations to physiotherapy service at public hospitals in KwaZulu-Natal, South Africa

Background : Individuals who have undergone a lower limb amputation require comprehensive rehabilitation from the multidisciplinary team to ensure optimal treatment outcomes and social integration. Physiotherapists play a pivotal role within the multidisciplinary team and offer patients physical and psychosocial rehabilitative care. Determining patients’ satisfaction levels and exploring factors affecting adherence to physiotherapy interventions can inform practice and improve service delivery of rehabilitation within resource poor settings such as South Africa. Objectives: To determine the level of satisfaction with physiotherapy services rendered to acute and sub-acute in-patients with lower limb amputations and to explore factors affecting adherence to physiotherapy intervention. Methods: A prospective survey of 35 patients with lower limb amputations from four public hospitals in South Africa was undertaken. A modified version of the Hampstead rehabilitation centre patient satisfaction questionnaire was utilised. Results: Majority of participants were satisfied with the physiotherapy services whilst a few reported dissatisfaction. Three themes emerged whilst exploring the patients’ experience relating to adherence to physiotherapy programmes. Themes included service delivery, patient-therapist interaction and participation barriers and facilitators. Conclusion: Recommendations aimed to improve quality of care and healthcare outcomes thereby enhancing the participants’ adherence to the physiotherapy programme.


Introduction
Patient satisfaction within the rehabilitation framework needs to be established as it affects the success of management and adherence to treatment regimes. Satisfaction with healthcare services often impacts the quality of care and has consequent effects on the marketability of essential services. 1 Although, patient satisfaction is multidimensional and can be jaded by emotion, rehabilitation professionals can use the feedback to improve or modify practice. 2 Furthermore, by exploring the factors that affect adherence to rehabilitation, professionals can understand the effect of emotion and personal experience on the service offered. Patients with lower limb amputations are among the rehabilitation recipients of ongoing care. They have multiple physical, psychological, environmental and socio-economic barriers and require patient-centred, comprehensive rehabilitation from the multidisciplinary team to ensure optimal treatment outcomes, social integration and economic self-sufficiency. Physiotherapists are an essential component of the multidisciplinary team 2 , and offer patients the future of optimal function in daily life. Patient co-operation and willingness to participate in the rehabilitative process is a key element of physiotherapy, as it is a scope of practice involved with the functioning of individuals, as well as optimizing independency 3 . benefit of such services. 1,2 Facilitators of patient satisfaction highlighted in the literature was the development of an effective communication basis with the therapist; the patient is treated with humility and acknowledged as an individual and when the therapist displays confidence in the patient as well as themselves. 4 Patients who are pessimistic may be inclined to perpetuate negative experiences to friends and family and may not adhere to rehabilitation routines. 1,2 By gaining an understanding of patient perspectives the authors of this paper sought not only to determine the satisfaction of patients but further sought to explore factors that affect adherence to rehabilitation.

Methodology
Design: In order to achieve the objectives of this study, the authors chose a prospective cross-sectional survey design with use of both open-ended and closed-ended questions.

Recruitment and selection of participants:
Purposive sampling was employed in the selection of four public hospitals in the province of KwaZulu-Natal, South Africa. All four sites service amputee in-patients in the acute and sub-acute phases of rehabilitation.
Ethical considerations: Ethical clearance was obtained from the University of KwaZulu-Natal and permission was granted from the relevant authorities at study settings. Voluntarily consent for participation in the study was confirmed and no incentives were offered for participation in the study.
Inclusion criteria: Thirty-five adult in-patients with lower limb amputations met the inclusion criteria which included the following: patients had to have received physiotherapy for more than two sessions; they had to be within the acute and sub-acute stages of healing and had to be cognitively sound.

Data collection instrument:
A modified version of the Hampstead rehabilitation centre patient satisfaction questionnaire 2 was utilised. For purposes of this study, the instrument was translated into isiZulu prior to a pilot study. The survey comprised twelve closed-ended questions that required responses using a five point Likert scale on satisfaction of physiotherapy services. The questions were positively phrased which deferred from the original survey 2 as the negative questions proved to be a challenge for participants during the pilot stage of this study. Content validity was ensured through having the questionnaire appraised by researchers in the field. The final data collection instrument consisted of three sections. Section 1 had questions related to demographic data. Section 2 included the modified Hampstead rehabilitation centre patient satisfaction questionnaire 2 and Section 3 included 4 open-ended questions related to factors that affect adherence to treatment.

Data analysis:
With the assistance of a statistician, the data from the questionnaire was analysed using the Statistical Package for Social Sciences (SPSS) version 21.0 and was reflected as descriptive statistics. Cronbach's Alpha which measures internal consistency of the questionnaire was also computed. The authors opted for a thematic analysis 6 for the four open-ended questions. Trustworthiness and credibility were ensured during the qualitative analysis stage to ensure rigor. 6

Results
Thirty five patients participated in the study, 14 were female and 21 male. Majority of the participants were married. The mean age was calculated to be 56 years.
Twenty four patients were of African ethnicity, 8 Indian, 2 White and 1 of Mixed descent. One participant had a tertiary education while the other patients were unemployed or had low income jobs. Table 1 illustrates the results of the closed-ended questions and the frequencies of responses. The general trend reflected that majority of the participants were satisfied with the Physiotherapy service. Cronbach's alpha was computed to determine the internal consistency of responses and revealed a score of 0.847 which indicates a high level of consistency.

Results of Survey
Results of the survey indicate that patients were generally satisfied with the physiotherapy service. Patients who are satisfied with the service delivery are adherent to therapy regimes and will in turn perpetuate positive reference and referrals to the rehabilitation practice 1 . A study by Stiller 2 iterates the necessity for assessing patient satisfaction as it is a valuable component in the evaluation of health-care outcomes in healthcare settings. A positive outcome indicates a good standard of physiotherapy care but the recommendations need to be addressed to optimize quality of care offered in practice.
In an endeavour to explore amputee in-patients satisfaction and adherence to the physiotherapy service three pertinent themes emerged i.e. Service delivery, Patient-practitioner interaction and participation barriers and facilitators.

Service delivery
The three sub-themes that emerged included the therapist's conduct and professionalism, protection and safety and lastly collaboration and communication. Within the therapists' conduct and professionalism sub-theme, the personal and professional qualities of the physiotherapist are considered essential particularly in situations where patients' privacy is threatened. Respect and empathy were expressed as fundamental in quality care as cited in another study. 9 The bioethical principle of non-maleficence where health care providers should avoid causing harm to their patients was echoed, by the therapist's conduct in this study. They ensured patients' safety was maintained as a priority in management. 10 The first intent to do no harm is the foundation of medical ethics in every situation, and results subsequently lead to the development of a mutual trusting relationship between patient and physiotherapist which ensured satisfaction with the service. 10 On the contrary this principle was not upheld in the management of a single patient in this study and this resulted in feelings of fear and dissatisfaction during the intervention sessions.

Patient-practitioner interaction
The communication between the patient and practitioner was explored as this influenced patient satisfaction and adherence to physiotherapy treatment. Effective communication consisted of educating patients on their condition, clear instructions and offering feedback to patients on their progress. Analogously, Beattie 11 found a positive correlation with patient-practitioner interaction and satisfaction with therapy. The shared information, education and time spent with the patient reflected greater patient fulfilment. Patients' were encouraged by the therapists' use of lay language and empathetic listening skills. Congruently, Brokalaki 12 emphasized patients distaste for technical language, poor feedback and depersonalized care when communicating with their practitioner. The patients in this study believed that gaining feedback through constructive reporting offered them a clear understanding of their progress continuum. When these were ensured, patient satisfaction and adherence was secured.
Motivation was a driving force that encouraged patients' to adhere to therapy. Patients showed appreciation toward their physiotherapists when the therapist encouraged their active involvement in their personal health and care. As a result, motivation and feedback offered to patients' on their progress, positively affected compliance to their ward exercise program. Functional outcome can be affected by patients' levels of motivation and in turn can result in positive rehabilitation outcomes of treatment 13 . A rehabilitation regimen was studied in patients with bilateral amputation of lower extremities and once again motivation reappeared as a contributing factor 14 .

Participation barriers and facilitators
The theme of Participation barriers and facilitators explored organizational and environmental factors, the therapy rendered to patients and personal factors. This theme encompassed the barriers and facilitators that impeded satisfaction and thus affected adherence. The organizational and environmental subtheme incorporated various factors that contribute to an effective therapy session. This included using the correct equipment, ensuring privacy, ensuring sufficient treatment space and adequate treatment time. Petek Ster 15 in their study also proposed that the duration of treatment and consultation time plays an important role in the satisfaction of patients. The study argued that treatment time is affected by the therapist's workload, the condition being treated, organizational aspects and the relationship the therapist shares with the patient. 15 In Stiller's 2 study recommendations to improve the physiotherapy service African Health Sciences Vol 15 Issue 2, June 2015 included the equipment; the study did-not detail the challenges with the availability or suitability of equipment. In this study however, participants complained about the lack of equipment as well as the availability during therapy sessions which is common in resource poor settings.
Focusing on ensuring privacy, patients were encouraged by the therapists' handling and maintenance of their privacy during rehabilitation sessions. Karro 16 emphasized the importance of patient privacy in securing the patient's dignity and confidentiality. The South African Patients Right Charter states that "Privacy is a right", thus individuals' privacy should always be ensured and protected by the healthcare provider. 17 Personal barriers to adherence to rehabilitation included the aspects that affected the well-being of participants and included pain experienced, feelings of being emotionally burdened, stigmatization and psychological issues. Pain often caused patients' to be averse to exercises. Although pain is a barrier to rehabilitation and limits function 18 , it is a factor that can be managed by physiotherapists. A study of in-patient physiotherapy rehabilitation of amputee patients proved to reduce bodily pain and aided in patients' functional ability 19 .
A study by Horgan and MaclaChlan 20 stated that in the acute phase post amputation psychological factors such as depression contributed to patients having lower levels of mobility, greater levels of activity restrictions, increased feelings of vulnerability and poor self-rated health. However, a study of amputee patients receiving psychosocial rehabilitation for the management of pain medication as well as behavioural problems proved to be successful. 21 The referral of patients' to psychosocial therapy in this study would aid rehabilitation. Furthermore, issues of stigma and emotional grief could be addressed with psychosocial rehabilitation by a trained professional within the multidisciplinary team. 21 A patient-centred, multi-disciplinary team approach is crucial in addressing the emotional, social and physical needs of amputee patients. 2 Some patients in this study were not referred timeously to other active members of the team despite the evident need; this implied a lack of effective collaboration between healthcare professionals. A study by Chetty and Maharaj 22 identified the importance of teamwork but also added that impediments to collaboration were communication barriers and lack of understanding of roles within the team.
Amongst the facilitators of participation in therapy was patients' setting their own self-goals. This ensured that they were motivated to perform their exercise programme. Stiller 2 recommended that patient and practitioner should work together in setting achievable goals for rehabilitation and should be guided by patient's expectations of therapy. Other patients were motivated socially to return home so that they could be reunited with their friends and family. Furthermore, many of the patients were the breadwinners of their household hence they were obligated to speedily recover so they could return to work and provide for their families. Pre-operative employment proved to favourably affect the post-operative functional ability of patients in a study by Pohjolainen and Alaranta 23 . Career path and achievement also positively influences amputee patient's psychosocial status and subsequently will affect patients' well-being and health. 24 Some patients in the study adhered to therapy regimens as they were driven to achieve their premorbid state of functioning as self-sufficient individuals. 24 The design of the therapy regime was influential on the adherence of patients. A stimulating exercise programme was adhered too and a lack of lustre regime was abandoned. Group therapy was a major contributor to patients' adherence with regards to their exercise regimen. It promoted a feeling of social support and the shared experiences kept patients motivated. Results in the study by Lubcke 10 were in keeping with the current study as participants' felt encouraged and supported when exercising with individuals with similar conditions.

Conclusion
The findings in the study support the importance of evaluating patient satisfaction and factors affecting adherence in offering quality rehabilitation in health care. Although it is specific to the context of the study, it is valuable in emphasizing the importance of evaluating health care delivery. It provides healthcare practitioners' with tools to not merely evaluate care but to further improve the standard of delivery. 2 The study could be undertaken at regular intervals at single sites incorporating multiple service providers as an essential measure to impact health care outcomes in resource poor settings such as South Africa.