International Journal of Public Health Science (IJPHS)

Vol. 10, No. 4, December 2021, pp. 778~784

ISSN: 2252-8806, DOI: 10.11591/ijphs.v10i4.20876  778

Awareness, perception and acceptability of digital

physiotherapy intervention among Malaysian physiotherapist

Rajkumar Krishnan Vasanthi, Lee Cai Ling, Yughdtheswari Muniandy

Faculty of Health and Life Sciences, INTI International University, Malaysia

Article Info ABSTRACT

Article history: Digital health intervention (DHI) can solve the patient's problem, such as
geographical inaccessibility, delayed provision of care, low-level adherence
Received Jun 8, 2021 to clinical protocols, and financial burden. DHI does not necessary to work
Revised Aug 18, 2021 as a substitution for a functioning health system but helps strengthen its
Accepted Aug 25, 2021 function. Therefore, this study aimed to determine the awareness, perception,
and acceptability of digital physiotherapy intervention (DPI) among
Malaysian physiotherapists. A total of 209 practicing physiotherapists
Keywords: representing all the regions in Malaysia participated in this online self-
reported questionnaire, including demographics profile, continuous
Acceptance professional development, awareness, perception and acceptability of DPI.
Awareness Analyzed the collected data to determine the knowledge of DPI by using
Digital physiotherapy descriptive statistical methods. A 75.1% of the Malaysian physiotherapist
Intervention aware of digital physiotherapy intervention, 69.38% perceived it reduces the
Perception cost for face to face, reduce the time for traveling 47.85%, improve
adherence to exercises 42.58%, 78% of them agree with the DPI and 75.1%
of them accepted to recommend the digital tools to their patient. Malaysian
physiotherapists are aware, agree and recommend the digital physiotherapy
intervention to their treatment plan. However, it should still raise awareness
about digital physiotherapy intervention to lead them to the future.
Developing new digital tools, utilization, and overcoming the various
healthcare institutions' low acceptability considering the cost, conventional
interventions, and time-consuming should be strategized in Malaysia.
This is an open access article under the CC BY-SA license.

Corresponding Author:
Rajkumar Krishnan Vasanthi
Faculty of Health and Life Sciences
INTI International University
Persiaran Perdana BBN, Putra Nilai, 71800 Nilai, Negeri Sembilan, Malaysia
Email: [email protected]/[email protected]

1. INTRODUCTION
The arrival of the digital era computers, communication, and the impending era of cognitive
computing has altered our modern culture. The roots of this digitalization transformation go deep and are
widely dispersed throughout the world [1]. According to the Fourth Industrial Revolution (IR 4.0), artificial
intelligence will take many future jobs. Furthermore, to improve the delivery of health care for diverse
illnesses, a variety of electronic (eHealth), mobile (mHealth), telehealth, and telemedicine approaches have
been created [2] that collectively referred as digital health.
According to the World Health Organization (WHO) [3], the digital health intervention defined as
digital and mobile technologies is used to support health system needs. Therefore, the WHO recommends
emerging digital intervention to healthcare for improvement that can solve the patient's problem, such as
geographical inaccessibility, delayed provision of care, the low-level of adherence to clinical protocols, and

Journal homepage: http://ijphs.iaescore.com

Int. J. Public Health Sci. ISSN: 2252-8806  779

costly to the patient. It has the potential to strengthen the coverage and quality of health services. The digital
health intervention does not work as a substitution for the functioning health system but enhances the health
system function [4].
The adherence to the therapeutic exercise is the key to benefit in a clinical outcome such as the
physical function, pain and quality of life. A recent study showed that methods to improve the patient
adherence with medical intervention need to be multifactorial and be provided in combination with
conventional care, the reminder, information, self-monitoring, reinforcement, counselling, family therapy,
telephone follow-up, psychological therapy, supportive care and education. There is numerous digital
physiotherapy intervention in the form of web-based or mobile application programmers such as
“Neuroforma” [5] and “Taxonomy for rehabilitation of knee conditions (TRAK)” [6] which assist the
rehabilitation at home. These technologies are tools that can help physiotherapists and the general public
have more efficient workflows and will transform rehabilitation from an episodic to a continuous-care
approach, enabling patients to get integrated therapy that is smoothly integrated into their daily life [7].
It is believed that digital physiotherapy intervention benefits the patient's performance, self-
management, and adherence to the exercise program at home and in improving the patient's health status as
stated in a narrative review [8]. Patient-centred digital applications can provide recovery with multifunctional
support, including evidence-based education, support for specific self-care activities, biometrics and
symptom monitoring, encourage contact between medical professional and patient, and promote holistic self-
management. Nonetheless, there are many limitations, including limited usability, awareness and training of
current and the emerging digital apps, limited participation of eligible rehabilitation health care providers in
the development and testing of these tools [9].
Dicianno [10] concluded that advancement of mHealth technology had altered the way we provide
and think about giving treatment to patients with chronic conditions and how people maintain their health and
well-being in the community; however, concerning the long-term consequences, acceptability, costs and risks
of such interventions that require further study. In 2020, Coronavirus disease 2019 (COVID-19) an outbreak
had affected 213 countries and the Government of Malaysia enforced Movement Control Order, which
begins on March 18, 2020 [11]. Malaysia's telehealth industry growth during COVID-19 pandemic and
teleconsultation services were established. Malaysia aspires to be a nation of healthy individuals, families,
and communities by implementing a health-care system that is “equitable, affordable, efficient,
technologically appropriate, environmentally adaptable, and consumer friendly, with a focus on quality,
innovation, health promotion, respect for human dignity, individual responsibility, and community
participation for improved quality of life [12]. We must guarantee that we learn in the same way from this
period of struggle (COVID-19), and that we sustainably implement this new dawn of digital health practices
in future care models [13].
The pandemic led Malaysian physiotherapists to adopt cutting-edge remote methods and digital
tools to improve and adhere to their clients' treatment procedures. Because the DPI is a novel approach of
treating or consulting clients, it is important to understand the physiotherapist's level of awareness,
acceptance, and perspective. So that we can break down obstacles and raise awareness about how to use
digital interventions. Therefore, this study aimed to determine the level of Awareness, Perception and
Acceptability of Digital Physiotherapy Interventions among Malaysian Physiotherapist.

2. RESEARCH METHOD
2.1. Study design and procedure
A cross-sectional survey questionnaire was developed, validated and distributed through an online
platform between February 2020 and April 2020. Total 209 Malaysian Physiotherapist representing all the
regions consented to and responded to the five-section questionnaires. The questionnaire addresses the
demographics profile, which includes gender, age, and level of education, work experience and sectors,
followed by their continuous professional development, awareness of digital interventions, benefits and
limitation of digital intervetions and acceptability in terms of not recommending and disagreeing of DPI.
Collected data statistically analyzed and discussed as shown in as shown in Figure 1.

2.2. Ethical
Obtained Ethical approval before the data collection from the Faculty of Health and Life Sciences –
Research and Ethical Committee, INTI International University (INTI-IU/FHLS-
RC/BPHTI/7NY12019/002). Any benefits, possible risks, or inconveniences and rights to withdraw anytime
during the study's survey clearly explained before the consent obtained from the participated Malaysian
Physiotherapist.

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Figure 1. Flowchart of the research process

2.3. Statistial analysis

IBM statistical package for the social sciences (SPSS) in Mac OS Version 26 was used to analyze
subjects' demographic data using descriptive statistics, including frequency distribution, percentage, mean
and standard deviation. The other sections, such as continuous professional development, awareness,
perception, and acceptability of DPI, were analyzed using descriptive statistics consisting of frequency
distribution and percentages.

3. RESULTS AND DISCUSSION

Overall, the mean age is 29.93±4.69. Highest education level answered the questionnaire are
diploma graduates, which is 44.5% currently the diploma graduates represent more percentage when
compare to other level. Since private practice are booming in Malaysia 53.14% respondents are from private
centers and home/locum physios followed by hospital set up including private and government 38.8% as
shown in Table 1.

Table1. Demographic data

n Percent
Gender
- Male 85 40.70%
- Female 124 59.30%
Age, Mean +SD 29.93±4.69
Level of education
- Diploma certificate 93 44.5
- Advanced diploma 30 14.4
- Bachelor’s degree 76 36.4
- Master degree 9 4.3
- Doctoral degree 1 0.5
Work experience Mean +SD 5.79±3.83
Working sector
- Government hospital 42 20.10%
- Private hospital 39 18.70%
- Community setting 4 1.90%
- Clinics/centers 72 34.44%
- Home physio 39 18.70%
- Higher education institute 13 6.20%

Malaysian Physiotherapist updates frequently their knowledge 78%, which is the key factor in
adopting recent advances in evidence based Physiotherapy practice 46.4% as shown in Table 2. Due to
frequent updating the knowledge, 75.1% of them are aware of DPI. The pathways to get awareness, the
majorities are online 60.3%, but unfortunately 55.5% didn’t notice physiotherapists using DPI in Malaysia
as shown in Table 3. Malaysian Physiotherapist perception on the benefits of DPI is equally divided among
various areas that include communication, to check patient health status, provide educational and training
content, provider to provider telecare and decision making support as shown in Table 4.

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Table 2. Continuous professional development

n Percent
Frequent update No 46 22%
Yes 163 78%
Last update Recently 87 41.6%
< 1 Year 62 29.7%
1 - 5 Years 55 26.3%
5-10 Years 4 1.9%
> 10 years 1 0.5%
Update method Through another physiotherapist 43 20.6%
Journal articles 97 46.4%
Advertising campaign 38 18.2%
Attend courses or workshop 31 14.8%

Table 3. Awareness of digital physiotherapy intervention

n Percent
No 52 24.9%
Awareness of DPI
Yes 157 75.1%
No 64 30.6%
Knowledge of digital intervention
Yes 145 69.4%
Book 6 2.9%
Online 126 60.3%
Friend 20 9.6%
Pathway to get the information
Colleague 27 12.9%
Courses 21 10%
Campaign 9 4.3%
No 116 55.5%
Notice people ustilising DPI
Yes 93 44.5%

Table 4. Benefits of digital physiotherapy intervention

n Percent
Provider-to-Provider telemedicine 84 40.19%
Targeted patient communication 107 51.20%
Health worker decision support 78 37.32%
Tracking of the patient's health status and services 72 34.45%
Provision of educating and training the health worker 44 21.05%

High percentage of Malaysian Physiotherapist assumes that DPI will costlier and it is not accessed
by all the clients as shown in Table 5. However from the patient point of view, nearly 50% of therapist
understood, accepted and said it could reduce the cost for face to face, reduce the time for travelling and
more importantly it improves adherence to exercises as shown in Table 6. DPI was mostly accepted by
Malaysian physiotherapists, except few of them do not recommend because it cannot ensure exercise
adherence (0.96%) and not widely used (4.78 %), and 1.91% percent believe it will not benefit the patient
and is not a holistic approach as shown in Table 7.

Table 5. Limitation of digital physiotherapy intervention

n Percent
Cost 123 58.85%
Inaccessibility to patient 134 64.11%
Time consuming 26 12.44%
Not suitable for all ages 22 10.53%
Low public acceptability 7 3.35%
Unstable connectivity 5 2.39%
Not for all patients 51 24.40%

Table 6. Benefits of digital physiotherapy intervention for patients

n Percent
Reduce time for travelling 100 47.85%
Reduce cost for face to face 145 69.38%
Improve adherence to exercises 89 42.58%
Improve self-management 25 11.96%
Learn more about diseases and exercises 23 11.00%
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Table 7. Reasons for disagreeing and not recommending the digital physiotherapy intervention
n Percent
Troublesome 3 1.44%
Not for physiotherapy 4 1.91%
services
Delaying patient progression 5 2.39%
Not applicable 3 1.44%
Face to face is better 7 3.35%
Reasons to Cannot assess patient 11 5.26%
disagree Digital physiotherapy 1 0.48%
intervention is not well
developed yet
Not suitable for the patient who 6 2.87%
needs manual therapy
Cannot track patient 6 2.87%
progression
Cannot ensure adherence of 2 0.96%
exercises
Not common to use 10 4.78%
Does not bring benefits to 4 1.91%
Reasons of
patient
not
Not helpful 6 2.87%
recommend
Not realistic 1 0.48%
digital health
Applications not holistic 4 1.91%
application to
Not suitable for all patients 6 2.87%
the patient
Not necessary 3 1.44%
Physiotherapy treatment does 4 1.91%
not work well without physical
contact.

3.1. Discussion
The results showed that 75.1% of Malaysian Physiotherapist is aware of DPI and 69.4% understand
the facts about it but in contrary more than 50% do not notice people using digital physiotherapy
intervention. Indicating that digital physiotherapy interventions are still not common to use even though they
are aware, which is supported by Malliaras et al. [14] that although allied health clinicians used telehealth
during the coronavirus pandemic, they found constraints that may prevent continuing use of telehealth
beyond the current pandemic.
Furthermore, almost half of them think they could benefit from digital physiotherapy intervention,
while the other half believe they cannot or maybe helped. Majority of them agree that the targeted patient
communication and provider-to-provider telemedicine are the most significant benefits. WHO stated that the
provider-to-provider telemedicine could improve the access to quality care and reduce the isolation of health
workers a remote setting. The targeted client communication indicates transmitting health content or
information to a specific patient based on their health status and demographic profile [3]. Approximately 70%
of Malaysian Physiotherapist agreed that the digital tools could solve the problems for patients, which
supported in a narrative review by Rajkumar et al. [8] that digital intervention believed to have an impact on
the client's performance, self-management and improve adherence of exercise program at home.
Developing and creating awareness on digital intervention tools are crucial as 69.38% of Malaysian
Physiotherapist accepted that it could reduce the cost for face-to-face, time for travelling 47.85%, improve
adherence to exercises 42.58%, improve self-management 11.96% and get more information about diseases
and practices 11%. Research shows the viability of a digital health program in cardiac rehabilitation,
reducing cardiovascular risk factors and showing dramatic decreases in clinically relevant results over
regular cardiac rehabilitation, such as re hospitalizations and emergency department visits [15], [16].
Another study reveals that medical community is set to confront significant structural changes that will alter
our workflow and communication channels, with telemedicine emerging as the most viable alternative for
protecting the safety of health care workers and patients [17]. Further analysis in our study identified that;
equally, they feel that there is still a potential limitation of DPI due to affordability of the cost by the patient
or the institute 58.85%, inaccessibility to patient 64.11%, time-consuming in delivering the care 12.44% and
some of the least limitation are connectivity issues, not suitable for all populations and low public
acceptability. WHO [4] stated that emerging digital tools of intervention in healthcare could solve the
patient's problem, such as geographical inaccessibility, delayed provision of care, low-level of adherence to
clinical protocols, and costly to the patient.
A study reported that the combination of digital physiotherapy intervention and face-to-face
physiotherapy increases their confidence and motivation during their rehabilitation [6], which is supported
more than half of Malaysian Physiotherapist, stated that they would be applying digital tools in their treatment

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Int. J. Public Health Sci. ISSN: 2252-8806  783

plan. Signifying, they agree with digital health and willing to step into the future. Moreover, 69.4% agree that
combining digital health intervention with face-to-face physiotherapy sessions is better than conventional ones.
On the contrary, findings show that an App-based intervention is an efficient treatment for Low Back Pain
patients and is superior in conjunction with online physiotherapy education as a multidisciplinary back pain
app [18]. About 78% of Malaysian physiotherapists agree and 75.1% ready to recommend the digital
physiotherapy intervention. However, still, less than 5% disagree and not recommend DPI because face to face
is the essence of physiotherapy care, digital tools are sometimes unable to assess the patient as the explanation
of discord, devices are not well developed, complicated in tracking progression, not realistic to all population
and even at times, cannot deliver holistic care to the clients. Even in a study done by Andrews et al. [19] Older
adults are encouraged to use digital technology to enhance their mental health. However, there are still
obstacles that developers need to overcome to access them for this demographic.
In our study, Malaysian Physiotherapist prefers face-to-face physiotherapy sessions as some
techniques or treatment, which cannot be delivered through digital intervention, which is underpinned by L
Bearne et al [20] in which, they concluded that physiotherapists should consider combining evidence-based
remote evaluation and tele-rehabilitation with face-to-face consultations. A study conducted to validate the
feasibility of a remote patient monitoring (RPM) system. The results found that RPM evaluate patients
undergoing total knee arthroplasty (TKA) in mobility and rehabilitation compliance, which found engaging
[21]. Furthermore, digital tools are still developing as we are still in the age of promise rather than delivery
and limited confidence and knowledge to use of telehealth [22], [23]. Malaysian Physiotherapist that 75.1%
accepted recommending digital tools for intervention in the future to the patient, which is, supported the
Digital health approaches that can contribute positively to reducing the multi-faceted burden on the
individual, the economy, and society [24].
In overall, awareness should create among all Malaysian Physiotherapist on the digital
physiotherapy intervention in line with digital health Malaysia (DHM), which includes health professionals,
researchers, and industry collaborates to advance the digital health agenda. They have a clear vision of
promoting for future health that is accessible, available and affordable. One of the strategies is go-to-market,
which enable an unbiased platform to promote digital health solutions. Developing new digital tools to
overcome the acceptability of digital intervention among Malaysian Physiotherapist is crucially supported
by choosing the right theory to direct the implementation process and strategy selection; ensuring that
adequate attention is paid to implementation planning and a versatile approach to reacting to the emerging
barriers [25]. Furthermore, both training and regular exposure to telehealth practice promotes acceptance
and confidence [23], [26]-[29] and through education and timely information, the targeted information
offered has the ability to improve patient outcomes [30].
The limitation of this study included the cross sectional design, which precluded us from
establishing the causal link, so in future incorporating the digital intervention into the real world practice and
accessing the acceptability of DIP will be more reliable. Larger participants of Physiotherapists in Malaysia
could be recruited for generalizing the result. In future, we can study whether working experience or
qualification or any other demographic profile is associated with knowledge of digital intervention.

4. CONCLUSION
The Malaysian physiotherapists are aware, agree and recommend the digital physiotherapy intervention
to their treatment plan. However, it should still raise awareness about the digital physiotherapy intervention to lead
them to the future. The digital physiotherapy intervention's perception even controversy as they are still not
familiar with digital tools and its appropriate benefits and only some of them are using digital tools. Developing
new digital tools, its utilization, and overcoming the various healthcare institutions' low acceptability considering
the cost, conventional interventions, and time-consuming should strategize in Malaysia.

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