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

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.

Physiotherapy and its service in Nepal: implementation and status reported from facility surveys and official registers.

BACKGROUND: Physiotherapy is a growing profession in Nepal. Despite efforts to promote strengthening and development, there are still challenges in providing equitable access and availability to services, particularly in underserved areas. Updated information is needed to address challenges to provide proper planning for resource allocation. OBJECTIVE: To assess implementation of physiotherapy services and to explore plans, policies and the general status of physiotherapy in Nepal. METHOD: Implementation was assessed with a cross-sectional survey conducted in Province III containing closed-ended questions addressing physiotherapy services, human resources, charging and record-keeping systems, and accessibility. Stratified purposive sampling was used to select eligible facilities from the list of Department of Health Services. Official records were explored through visits to governing institutions and by reviews of registers and reports to obtain data and information on status, plans and policy. RESULTS: The survey included 25 urban and 4 rural facilities, covering hospitals and rehabilitation centres; both public (37.9%) and non-public (62.1%). Most facilities (79.3%) employed physiotherapists with bachelor's degrees. Average number of visits were 29.55 physiotherapy outpatients and 14.17 inpatients per day. Patient records were mainly paper based. Most (69%) used the hospital main card, while others (31%) had their own physiotherapy assessment card. Most referrals came from doctors. The most offered services were musculoskeletal, neurological, and paediatric physiotherapy. Daily basis charging was common. A single visit averaged 311 Nepalese rupees ≈ 2.33 US$. Convenience for persons with disabilities was reported as partial by 79% of outpatient departments. Official register data showed 313 master's and 2003 bachelor's graduates. Six colleges offered physiotherapy bachelor's degree, whereof one also offered a master's program. Government records revealed significant progress in physiotherapy in Nepal. CONCLUSION: The study highlights variations in physiotherapy services within a province owing to type, size and location, but also unwarranted variations. Despite the progress, implementation of physiotherapy services in the perspective of official records imply a need of systems for proper planning and monitoring. Physiotherapy provision in underserved areas warrants further attention.

Educating for Indigenous Health Equity: An International Consensus Statement.

The determinants of health inequities between Indigenous and non-Indigenous populations include factors amenable to medical education's influence-for example, the competence of the medical workforce to provide effective and equitable care to Indigenous populations. Medical education institutions have an important role to play in eliminating these inequities. However, there is evidence that medical education is not adequately fulfilling this role and, in fact, may be complicit in perpetuating inequities.This article seeks to examine the factors underpinning medical education's role in Indigenous health inequity, to inform interventions to address these factors. The authors developed a consensus statement that synthesizes evidence from research, evaluation, and the collective experience of an international research collaboration including experts in Indigenous medical education. The statement describes foundational processes that limit Indigenous health development in medical education and articulates key principles that can be applied at multiple levels to advance Indigenous health equity.The authors recognize colonization, racism, and privilege as fundamental determinants of Indigenous health that are also deeply embedded in Western medical education. To contribute effectively to Indigenous health development, medical education institutions must engage in decolonization processes and address racism and privilege at curricular and institutional levels. Indigenous health curricula must be formalized and comprehensive, and must be consistently reinforced in all educational environments. Institutions' responsibilities extend to advocacy for health system and broader societal reform to reduce and eliminate health inequities. These activities must be adequately resourced and underpinned by investment in infrastructure and Indigenous leadership.

Health Professional Workforce Education in the Asia Pacific.

OBJECTIVE: To design and implement an international and interprofessional Global Learning Partnership Model, which involves shared learning between academics and students from Universitas 21 network with other universities with United Nations Millennium Development Goal needs. DESIGN: Two literature reviews were conducted to inform ethical aspects and curriculum design of the GLP model. Feedback from conference presentations and consultation with experts in education and public health has been incorporated to inform the current iteration of the GLP model. INTERVENTION: The pilot group of 25 students from U21 universities and Kathmandu University, representing six health disciplines will meet in Nepal in April 2016 for a shared learning experience, including a one week university based workshop and three week community based experience. OUTCOME MEASURES: A multi-phase, mixed method design was selected for the evaluation of the GLP model, utilising a combination of focus groups and questionnaires to evaluate the efficacy of the placement through student experience and learning outcomes in cultural competency, UN SDG knowledge, community engagement and health promotion skills. RESULTS: The literature review demonstrated that cultural awareness and cultural knowledge were improved through participation in cultural immersion programs that incorporated preparatory workshops and clinical experiences. Data will be gathered in April 2006 and the results of the evaluation will be published in the future. CONCLUSIONS: The GLP model proposes a project around the fundamental concept of engagement and sharing between students and academics across universities and cultural contexts to build capacity through education, while capitalising on strengths of existing global health placements. Further the inclusion of host-country students and academics in this learning exchange will promote the establishment of an international and interprofessional network for ongoing health promotion. Significance for public healthThe Global Learning Partnership model aims to contribute to the capacity building of a health workforce that is capable of working effectively in cross cultural and interprofessional health care teams. A shared public health focused global placement has the potential to catalyse collaborative relationships between educational institutions in the Asia Pacific region.

The use of the International Classification of Functioning, Disability and Health to understand the health and functioning experiences of people with chronic conditions from the person perspective: a systematic review.

PURPOSE: This systematic review examines the literature to identify the context and extent of implementation of the International Classification of Functioning, Disability and Health (ICF) model to understand the experience of health and functioning in persons with chronic conditions from the person perspective. METHOD: The literature search was conducted through five electronic databases between 2001 and December 2012. Reference lists of included papers were also searched. Articles in which the ICF was used to understand the health and functioning experience of adults with chronic conditions from the person-perspective were included. Data were extracted and analysed to identify the year of publication, geographical location, health condition, context of ICF use, authors' remarks and identified limitations of the ICF. RESULTS: Thirty-seven qualitative and mixed-methods studies were included representing 18 countries and a range of chronic conditions. The ICF was found to be used to elicit and analyse people's narratives, with the majority of studies reporting that the ICF provides a comprehensive analysis of experiences and needs from the person perspective. Some limitations to its use and the need to classify the "personal factors" component were reported. CONCLUSION: The ICF has been used to provide a comprehensive understanding of health and functioning in persons with chronic conditions from the person perspective, although there are currently relatively few studies which have used the ICF in this context. Limitations regarding its use were reported which should be considered by users of the model and during its revision process. IMPLICATIONS FOR REHABILITATION: The ICF encourages a bio-psycho-social and person-centred approach to healthcare and may provide a useful tool for guiding clinical assessment and encouraging clinicians to consider the multitude of factors which impact health, which may result in more specific and individualised treatment targeted at individual needs. Using a common framework that can be understood across health disciplines may enhance interdisciplinary communication and collaboration, improving health care delivery. The ICF may be used to compare perspectives of individuals and their health professionals and to identify people's needs that are not adequately being addressed, which may have significant implications for improving healthcare provided and overall health outcomes.

What counts as effective communication in nursing? Evidence from nurse educators' and clinicians' feedback on nurse interactions with simulated patients.

AIM: To examine the feedback given by nurse educators and clinicians on the quality of communication skills of nurses in interactions with simulated patients. BACKGROUND: The quality of communication in interactions between nurses and patients has a major influence on patient outcomes. To support the development of effective nursing communication in clinical practice, a good understanding of what constitutes effective communication is helpful. DESIGN: An exploratory design was used involving individual interviews, focus groups and written notes from participants and field notes from researchers to investigate perspectives on nurse-patient communication. METHODS: Focus groups and individual interviews were held between August 2010-September 2011 with a purposive sample of 15 nurse educators and clinicians who observed videos of interactions between nurses and simulated patients. These participants were asked to give oral feedback on the quality and content of these interactions. Verbatim transcriptions were undertaken of all data collected. All written notes and field notes were also transcribed. Thematic analysis of the data was undertaken. FINDINGS: Four major themes related to nurse-patient communication were derived from the educators' and clinicians' feedback: approach to patients and patient care, manner towards patients, techniques used for interacting with patients and generic aspects of communication. CONCLUSION: This study has added to previous research by contributing grounded evidence from a group of nurse educators and clinicians on the aspects of communication that are relevant for effective nurse-patient interactions in clinical practice.

The use of the international classification of functioning, disability and health (ICF) in indigenous healthcare: a systematic literature review.

INTRODUCTION: The International Classification of Functioning, Disability and Health (ICF) was endorsed by the World Health Organisation (WHO) in 2001 to obtain a comprehensive perspective of health and functioning of individuals and groups. Health disparities exist between Indigenous and non-Indigenous Australians and there is a need to understand the health experiences of Indigenous communities from Indigenous Australian's perspectives in order to develop and implement culturally appropriate and effective intervention strategies to improve Indigenous health. This systematic review examines the literature to identify the extent and context of use of the ICF in Indigenous healthcare, to provide the foundation on which to consider its potential use for understanding the health experiences of Indigenous communities from their perspective. METHODS: The search was conducted between May and June 2012 of five scientific and medical electronic databases: MEDLINE, Web of Science, CINAHL, Academic Search Complete and PsychInfo and six Indigenous-specific databases: AIATSIS, APAIS-health, ATSI-health, health and society, MAIS-ATSIS and RURAL. Reference lists of included papers were also searched. Articles which applied the ICF within an Indigenous context were selected. Quantitative and qualitative data were extracted and analysed by two independent reviewers. Agreement was reached by consensus. RESULTS: Five articles met the inclusion criteria however two of the articles were not exclusively in an Indigenous context. One article applied the ICF in the context of understanding the health experience and priorities of Indigenous people and a second study had a similar focus but used the revised version of the International Classification of Impairments, Disability and Handicap (ICIDH-2), the predecessor to the ICF. Four of the five papers involved Indigenous Australians, and one of the paper's participants were Indigenous (First Nation) Canadians. CONCLUSION: Literature referring to the use of the ICF with Indigenous populations is limited. The ICF has the potential to help understand the health and functioning experience of Indigenous persons from their perspective. Further research is required to determine if the ICF is a culturally appropriate tool and whether it is able to capture the Indigenous health experience or whether modification of the framework is necessary for use with this population.

Taking stock of interprofessional learning in Australia.

Changes in health service delivery and issues of quality of care and safety are driving interprofessional practice, and interprofessional learning (IPL) is now a requirement for medical school accreditation. There is international agreement that learning outcomes frameworks are required for the objectives of IPL to be fully realised, but there is debate about the most appropriate terminology. Interprofessional skills can be gained in several ways - from formal educational frameworks, at pre- and post-registration levels to work-based training. Research activity suggests that many consider that IPL delivers much-needed skills to health professionals, but some systematic reviews show that evidence of a link to patient outcomes is lacking. Australian efforts to develop an evidence base to support IPL have progressed, with new research drawing on recommendations of experts in the area. The focus has now shifted to curriculum development. The extent to which IPL is rolled out in Australian universities will depend on engagement and endorsement from curriculum managers and the broader faculty.

A clinical education and practice placements in the allied health professions: an international perspective.

This report describes the outcomes of extensive discussions surrounding clinical education and practice placement issues undertaken by an international group of allied health educators (in audiology, occupational therapy, physiotherapy, and speech pathology) who have met since 2001 as part of Universitas 21 Health Sciences annual meetings. The report outlines key issues associated with clinical education and practice placements from an international perspective and across these four allied health professions. The allied health practice context is described in terms of the range of allied health educational programs in Universitas 21 and recent changes in health and tertiary education sectors in represented countries. Some issues and benefits related to supervision during allied health students' practice placements are addressed. A new approach is proposed through partnership such that frameworks for the provision of practice placements can be created to facilitate student learning and educate and support clinical educators. A set of guidelines that can enhance partnerships and collaborative practice for the benefit of clinical education within complex and changing health/human service and educational environments is proposed.

Australian physiotherapy student intake is increasing and attrition remains lower than the university average: a demographic study.

QUESTIONS: Have student numbers (ie, intake and attrition) changed since the introduction of graduate entry-level physiotherapy courses in Australian universities? What is the impact of any changes in student numbers on university funding? What is the impact of any changes in student numbers on the workforce? Have student characteristics (ie, gender, country of origin, background) changed? DESIGN: Demographic study of 2003 graduates, 2004 student intake, and estimated 2007 student intake. PARTICIPANTS: Eleven Schools of Physiotherapy in Australia. RESULTS: In 2003, 836 new physiotherapists graduated, and in 2004, 1108 students commenced with the percentage of graduate-entry Masters and international students increasing. Compared to the overall average 25% attrition rate of students from university, the rate for physiotherapy students was less than 5%; the funding formula thus underestimates physiotherapy student numbers across the years of the courses. While it remains the case that in undergraduate and graduate-entry programs most physiotherapy students are female, a greater proportion of males are entering graduate-entry Masters programs than undergraduate courses. International student numbers are increasing in line with trends across the sector, but representation of Aboriginal and Torres Strait Islander students in physiotherapy courses was lower than within universities generally. CONCLUSIONS: The marked overall increase in student numbers and greater retention rate in the graduate entry-level courses puts physiotherapy at a disadvantage in relation to Department of Education, Science and Training student funding. While the substantial increase in new physiotherapists may serve to ease workforce demands in the short term, significant pressure on physiotherapy academics and clinical educators was evident.