Motivation and Awareness of Female Physiotherapists in Saudi Arabia toward Women Health Physiotherapy

Background: Pelvic floor disorders (PFDs) are a group of common conditions that create a great distress to the lives of many female patients. The role of women health physiotherapy (WHPT) in managing PFDs is crucial. Scarce data in the literature describe the awareness, attitude, and practice of WHPT among female physiotherapists and to the best of our knowledge, none are reported in Saudi Arabia. This paper hypothesizes that female physiotherapists in Saudi Arabia are less motivated to practice WHPT and that being less motivated have led to acquiring a lower level of awareness to the specialty. Additionally, it aims to explore the beliefs of female physiotherapists toward WHPT. Methods: An online questionnaire was distributed among female physiotherapists working in Saudi Arabia. Participants were asked to identify other colleagues to include in the sample. Reliability of the questionnaire was tested using a pilot study. Results: The majority of respondents [75.9%] are specialists and 69.2% reported years of experience ranging from 1 to 5. Around 46.9% of respondents were motivated to practice WHPT and 82.1% agreed that physiotherapy is important in treating PFDs. Additionally, Respondents who were motivated to practice WHPT displayed a significantly higher level of awareness to the specialty and understood the importance of pelvic floor rehabilitation (PFR) as an intervention for PFDs. Conclusions: There is adequate level of awareness of female physiotherapists in Saudi Arabia to WHPT and a great motivation to practice the specialty. The study highlighted the need to organize various educational programs and workshops that focus on WHPT and PFR.


INTRODUCTION
Pelvic floor disorders (PFDs) are a common distressing condition that greatly impacts patients' quality of life causing several physical, social, and psychological consequences. It is defined as a defect in musculature and endopelvic fascia that results in a variety of conditions, such as pelvic organ prolapse (POP), urinary or fecal incontinence, and chronic pelvic pain [1]. Different treatment modalities are well established for PFDs including surgical, medical, and conservative management. Importantly, pelvic floor rehabilitation (PFR) plays a major role as an effective treatment measure for PFDs and aims to improve the strength, endurance, and function of pelvic floor muscles [2].
Concerning the practice of physiotherapy in Saudi Arabia, bachelor programs in physiotherapy were introduced later in the kingdom compared to other countries. Over the past decade, the kingdom's understanding of the importance of physiotherapy as an effective treatment of various medical conditions is evolving as the number of universities offering a bachelor's degree in physiotherapy has increased from 6 to 16 [3]. Contrary to the United States and United Kingdom, in Saudi Arabia, patients are not permitted to directly access physiotherapists without a referral from other health practitioners [4,5]. In addition, little is known about the role of female physiotherapists in Saudi Arabia and their practice as well as the currently available subspecialties. Moreover, postgraduate study in physiotherapy was introduced later in the year of 2000 and included pediatrics, geriatrics, orthopedics, neurology, and cardiothoracic studies [6]. Unfortunately, there are no accurate local data about the numbers of registered women health physiotherapists and the specialized centers that offer women health physiotherapy (WHPT) services.
To our knowledge, no local data are available to describe the awareness, attitude, and practice of WHPT among female physiotherapists in Saudi Arabia. Thus, in this paper, we hypothesized that female physiotherapists in Saudi Arabia are less motivated to practice WHPT and that being less motivated have led to acquiring a lower level of awareness to the specialty. Additionally, it aims to explore the beliefs of female physiotherapists toward WHPT as a specialized practice.

METHODS
An online questionnaire was designed to gather the data required. It was provided to be accessed using either a link or a barcode. Once the questionnaire was accessed, there was an introductory cover letter explaining the aims of the paper and ensuring that participation is completely voluntary and that all responses will be handled with confidentiality. Also, it was explained that the study subjects' anonymity was ensured, and a consent was obtained from each participant prior to answering the questions. The questionnaire was kept short taking less than 5 minutes to complete.
The questions included in the questionnaire were grouped into demographic information and 5 other categories including motivation, awareness, education and training program factors, attitudes and beliefs, and employment and career factors. Seven questions were included under demographic information to identify the characteristics of the sample which included age, nationality, academic level, employee level, years of experience, workplace, and current region of workplace. The questions under the other 5 categories were in the form of a Likert scale. Two questions were included under motivation to assess whether female physiotherapists are motivated towards the practice of WHPT. The second category includes 5 questions to assess participants' understanding of the practice of physiotherapy and how important it is as an effective conservative treatment for PFDs. For education and training, 7 questions were included under this category to assess the presence of adequate educational programs, workshops, and training courses for WHPT. Five questions were included under attitudes and beliefs to gain an understating of physiotherapists' beliefs such as facing difficulties performing frequent vaginal examinations, feeling ashamed about being specialized in WHPT, and perceiving WHPT as ineffective and insignificant practice for treatment of PFDs. Lastly, employment and career category included 5 questions that aim to describe whether adequate number of job offers, and patients are available to encourage practicing WHPT.
To ascertain the reliability of the questionnaire, a pilot study was performed. The questionnaire was self-administered using barcodes to female physiotherapists working in different centers in the eastern region of Saudi Arabia and 30 participants were included in the pilot study. The Cronbach's alpha for the pilot study was 0.731 and no changes were made to the questionnaire afterwards. Female physiotherapists in different centers in the eastern region were asked to kindly participate in the study and to distribute the questionnaire to other colleagues that they know who are currently working as physiotherapists. The sample size was calculated using the formula n=z 2 × (1-)/ε 2 and the sampling technique was snowball sampling, a type of non-probability sampling. The study was approved by the institutional review board (IRB) of Imam Abdulrahman Bin Faisal University, Dammam. . Furthermore, correlation between motivation and awareness using Pearson's correlation was tested. There was a statistically significant positive small correlation between the two variables [r=0.33, p=0.000]. to illustrate, respondents who were motivated to practice WHPT and thought that it is an interesting practice, displayed more awareness towards the specialty and understood the importance of PFR as an intervention for PFDs.

DISCUSSION
Our null hypotheses in this study were that (1) physiotherapists are less motivated to practice WHPT and (2) being less motivated contributed to acquiring a lower level of awareness to practice the specialty. The responses obtained did not reflect the first hypothesis as the majority of participants were actually motivated to practice WHPT. Conversely, the second hypothesis was accepted as it was shown that the higher the motivation of female physiotherapists, the more aware they are about the importance and effectiveness of WHPT. The majority of physiotherapists included in the study are youngaged females with years of experience ranging from one to five and are general physiotherapists. Among our sample, it was noticed that physiotherapists who had less experience in the field were more motivated toward the specialty. While the majority of the sample included general physiotherapists, the responses reflected adequate level of motivation and awareness to WHPT. In contrast, the sample of another study conducted by Hagen et al. [7] included many women health physiotherapists the majority of which are senior specialists in urogynecology. Moreover, almost half of participants reported insufficient exposure and teaching opportunities to WHPT during training years. Additionally, a large majority reported not seeing many patients during their years of practice. This might be attributed to low level of public awareness leading to lower number of patients seeking medical care. This observation is comparable to the findings reported by Abhyankar et al. [8] which state that there is lack of awareness among patients to POP which led to delayed presentation. In Saudi Arabia, one study demonstrated moderate level of awareness of physiotherapy services and suggested the need to educate the public about the role of physiotherapy [9]. Hence, barriers such as low public awareness should be overcome to enhance medical access to female patients who require WHPT.
Pelvic floor rehabilitation has been shown to be an effective management option in 52 to 57% of POP patients [10]. The majority of physiotherapists involved in this study were wellaware of the effectiveness of PFR. In fact, physiotherapists who were motivated to practice WHPT displayed a higher level of awareness. Also, it was shown that participants who are more aware about the specialty believed that there is lack of adequate exposure to patients and teaching in the curriculum. Also, over half of participants agreed that they were less inclined to pursue a career in WHPT as they believe there is limited referral of patients by other health practitioners. Conversely, Odunaiya et al. [11] studied the utilization of physiotherapy among obstetricians and gynecologists in Nigeria and found that a large majority of participants referred their patients to WHPT, and that the majority referred their patients to general or state hospitals.
In a community with a conservative culture such as that of Saudi Arabia, it was postulated that female physiotherapists might be ashamed to identify themselves as women health physiotherapists and are reluctant to perform frequent vaginal examinations whether due to religious or other reasons. However, only a minority of respondents shared this belief. With regards to the financial aspects of WHPT, the responses varied greatly of how rewarding the practice is as only one-fourth of participants agreed that it is financially unrewarding. Similarly, in a study conducted to investigate the experiences of overseas trained physiotherapists working in Saudi Arabia, one third of respondents listed poor financial outcome as a reason of suboptimal local work experience [12].
To the best of our knowledge, there are no other questionnaires in Saudi Arabia with which to compare our findings. Some of the literature found locally described awareness to physiotherapy among the public and healthcare workers and some studies addressed the overall importance of physiotherapy in the treatment of many medical conditions such as low back pain. However, there is virtually no data on WHPT as a practice or the effectiveness of PFR in the treatment of PFDs and none on the perceptions of physiotherapists and the Saudi population to WHPT. Thus, the results of this questionnaire provide an insight about the current perceptions of female physiotherapists to WHPT. It also emphasizes the need to apply various WHPT training programs and educational courses as currently no accurate data about training programs are available in the kingdom. Thus, this paper forms the groundwork for further larger studies to better describe and signify the importance of WHPT.
The current study has several limitations. It is possible that the small sample size might have affected the responses obtained. Additionally, the sampling technique used might have influenced the equal distribution of the questionnaire among all regions of the kingdom. However, adapting a different sampling technique was not possible due to the circumstances created by the COVID-19 pandemic. Moreover, although online surveys are considered a relatively easy method of data collection, they have some downsides such as misidentification of participants.

CONCLUSION
The results of this study showed adequate level of awareness of female physiotherapists towards WHPT as well as a great motivation to practice WHPT. The study highlighted the need to organize various educational programs and workshops that focus on WHPT and PFR. Future studies are needed to determine the prevalence of PFDs among Saudi females and the role of WHPT in the management of these disorders.

ETHICAL APPROVAL AND CONSENT
In the cover page of the questionnaire, it was explained that the study subjects' anonymity was ensured, and a consent was obtained from each participant prior to answering the questions. The study was reviewed and approved by the institutional review board (IRB) of Imam Abdulrahman Bin Faisal University, Dammam.

AVAILABILITY OF DATA AND MATERIALS
Data sharing is not applicable to this article as no datasets were generated or analysed during the current study.