|Year : 2020 | Volume
| Issue : 2 | Page : 71-78
Awareness, acceptability, and willingness-to-pay for digital physiotherapy among patients in selected hospitals in a South-Western State of Nigeria
Emmanuel Chidozie Mbada1, Ayodeji Emmanuel Bamidele-Odewole1, Ernest Emezie Anikwe2, Ifeanyinwa Arize3, Clara Toyin Fatoye4, Ebere Cynthia Anikwe5, Francis Fatoye4
1 Department of Medical Rehabilitation, College of Health Sciences, Obafemi Awolowo University, Ile Ife, Nigeria
2 Department of Physiotherapy, University College Hospital, Ibadan, Oyo State, Nigeria
3 Department of Health Administration and Management, College of Medicine, University of Nigeria, Enugu Campus, Enugu, Nigeria
4 Department of Health Professions, Faculty of Health, Psychology and Social Care, Manchester Metropolitan University, Manchester, United Kingdom
5 Health Insurance Unit, University College Hospital, Ibadan, Oyo State, Nigeria
|Date of Submission||23-May-2020|
|Date of Decision||26-May-2020|
|Date of Acceptance||16-Jul-2020|
|Date of Web Publication||19-Nov-2021|
Ernest Emezie Anikwe
Department of Physiotherapy, University College Hospital, Ibadan, Oyo
Source of Support: None, Conflict of Interest: None
Background: Digital physiotherapy in line with global health coverage has become a salient field of physiotherapy practice where routine and innovative forms of information and communications technology are employed with the aim of facilitating effective delivery and access to physiotherapeutic services and resources. This study evaluated and determined the socio-demographic correlates of awareness, acceptability, and willingness-to-pay (WTP) for digital physiotherapy among patients. Materials and Methods: A total of 92 consenting patients who were 18 years and older responded in this cross-sectional study. An adapted tool on awareness, acceptability, and WTP for telemedicine services was adapted for use in this study. Data were analyzed using descriptive statistics of mean, standard deviation, and percentages; inferential statistics of Chi-square was used for test of association. Alpha level was set at P < 0.05. Results: The mean age of the respondents was 52.40 ± 15.62 years. There was a high rate of unawareness (91.3%), moderate-to-high acceptability (87.0%) and high WTP (88.0%) for digital physiotherapy, respectively. There was no significant association between the socio-demographic factors and each of acceptability and WTP for digital physiotherapy (P > 0.05). Conclusion: In spite of low awareness of digital physiotherapy, Nigerian patients attending physiotherapy clinics are willing to accept and pay for its use irrespective of socio-demographic variations.
Keywords: Acceptability, Awareness, Digital physiotherapy, Telerehabilitation, Willingness-to-pay
|How to cite this article:|
Mbada EC, Bamidele-Odewole AE, Anikwe EE, Arize I, Fatoye CT, Anikwe EC, Fatoye F. Awareness, acceptability, and willingness-to-pay for digital physiotherapy among patients in selected hospitals in a South-Western State of Nigeria. Digit Med 2020;6:71-8
|How to cite this URL:|
Mbada EC, Bamidele-Odewole AE, Anikwe EE, Arize I, Fatoye CT, Anikwe EC, Fatoye F. Awareness, acceptability, and willingness-to-pay for digital physiotherapy among patients in selected hospitals in a South-Western State of Nigeria. Digit Med [serial online] 2020 [cited 2022 May 22];6:71-8. Available from: http://www.digitmedicine.com/text.asp?2020/6/2/71/330759
| Introduction|| |
Digital health revolves around “the cultural transformation of how disruptive technologies provide digital and objective data available to both caregivers and patients, leading to an equal level of doctor-patient relationship with shared decision-making and the democratization of care''. Health care has become dependent on technologies in recent years. The digitalization of health care became inevitable due to the fact that; the level of medical knowledge continued to increase rapidly partly due to the quest for ease of duty and burn out syndrome among healthcare professionals. In recent years, attention in the popular media has been geared toward digital health technologies especially regarding medical health services and public health literature. The World Health Organization, acknowledged the potential of digital technologies to play a major role in improving public health. Delegates however, resolved at Geneva, Switzerland, in 2018 to urge member states, to prioritize the development and greater use of digital technologies in heath as a means of promoting the Universal Health Coverage and advancing sustainable goals.
The technology has been evolving at an exponential speed in the past decade and the evidence of a dramatic change is all around us such as self-driving cars, artificial intelligence, robotics, and many more. Digital health technologies, ranging from wearable sensors and portable diagnostic technologies to telemedicine tools and mobile health-care apps, have the potential to transform the health-care delivery system by empowering consumers to play an active role in their care and define what services are important to them. The use of technology in health-care system has significantly increased the choices people have in terms of remote access to health-care needs across the world.
Physiotherapy profession is beginning to adapt to these changes and has incorporated health technologies (Digital Physiotherapy) such as mobile health, virtual reality therapy, and telerehabilitation. Mobile health refers to the simple use of mobile computing and communication technologies in health care and public health. Mobile health interventions have been a useful means in reducing inactivity-related health risks by providing modes for delivering interventions to modify these behaviors and reduce health risk. Virtual reality refers to systems or devices that allow users to interact with computer-generated scenarios, objects, and events and may range from high-end systems where a user is immersed within a virtual environment through a head-mounted device, to nonimmersive lower-cost systems shown on flat-screen monitors., A key interest of virtual rehabilitation is its potential to increase the frequency and intensity of guided therapy that patients are able to receive, compared with standard approaches without creating additional burden on therapists' already heavily constrained time. Telerehabilitation is the application of telecommunication technology that provides distant support, assessment, and intervention to individuals with disabilities. According to Russell, telerehabilitation is an alternate means of providing all aspects of care including the interview, physical assessment, consultation, education, and training to clients at a remote location. There are several success stories of the implementation of telerehabilitation in the developed countries for delivering rehabilitation services. In Canada, for instance, the goal of telerehabilitation is to increase geographic accessibility and quality of care for the elderly. While in Finland, the use of telerehabilitation seem to have improve economic barriers through reduction of traveling cost and time. These show that rehabilitation practitioners are tuning into telerehabilitation as a way of improving access, enhancing the quality of care, and reducing costs of care. Some of the platforms of Telerehabilitation include videoconferencing platforms (Facetime, Skype and Zoom), wearable devices (Fitbit, AppleWatch), audio and video communication (Telephone, Podcasts, and YouTube), as well as many research-driven prototypes housed on a range of platforms.
In spite of the documented benefits of digital practice, one of the significant barriers to its uptake in some settings is the economic related factors that bother on imbursement/reimbursement from the user and providers' perspective. As digital physiotherapy practice is a rapidly evolving field, there is a need to analyze the clinical outcomes, acceptability, and the cost associated with digital physiotherapy. Digital physiotherapy should be accepted by intending user prior to the implementation of such scheme.
Willingness-to-pay (WTP) is the maximum amount that a person is willing to sacrifice to procure a good or avoid something undesirable and is used to measure benefits in public decision-making. The assessment of WTP for goods and services, using the contingent valuation method, is being increasingly used to value health-care services, especially in developing countries such as Nigeria. There are very few written studies on WTP for Digital Health Practice in Nigeria. For example, a study by Arize and Onwujekwe, observed that more than half of the patients at a tertiary care center in Nigeria, were willing to consider using telemedicine and pay to access the services to avoid the inconvenience of travelling to a doctor's office.
While, digital physiotherapy holds the potentials to help reduce or eliminate barriers to global health care in terms of distance, time and cost, its awareness, acceptability, and WTP for such services by patients in this part of the country is unknown. This study was therefore, aimed at evaluating the awareness, acceptability, and WTP for digital physiotherapy among patients in some selected hospitals in a south-western state of Nigerian.
| Materials and Methods|| |
This cross-sectional study recruited patients who were not <18 years of age, receiving physiotherapy treatment on outpatients basis at selected hospitals in Osun State, Nigeria. The study centers were Obafemi Awolowo University Teaching Hospital Complex (OAUTHC), Ile-Ife and Wesley Guild Hospital, Ilesa. Respondents who were excluded from the study were patients who did not understand English and/or Yoruba Language.
- An “Acceptability and WTP for digital Physiotherapy questionnaire” adapted from a study by Arize and Onwujekwe on “Acceptability and WTP for telemedicine services in Enugu State” was modified for the purpose of this study in which sections containing “telemedicine” was changed to “Digital Physiotherapy.” For assessing the WTP, the maximum amounts they were willing to pay were elicited using the Bidding Game (BG) question format. The BG has been shown to be a valid WTP elicitation question format in Nigeria. The respondents were presented with the hypothetical scenario of digital physiotherapy. In the BG iteration, they were then asked what the maximum amount they would be willing to pay for digital physiotherapy service. A uniform starting point of ₦500 was used
- A digital physiotherapy information brochure was also used to give a preview/few details about digital therapy.
Ethical approval of this study was obtained from the Health Research and Ethics Committee at OAUTHC, Ile-Ife. Permission of the respective heads of the department of physiotherapy in the respective hospitals was sought and obtained. The purpose of the study was well explained to the intending respondents. Participation was totally voluntary and utmost confidentiality was ensured. Informed consent was sought and obtained from respondents who indicated interest to be part of the study. A 5 min video explaining the concept of digital physiotherapy was then made available to the respondents. Questionnaires which included a “Digital Physiotherapy Information” Brochure and details of the concept were then administered to the respondents.
Descriptive statistics of mean, median, standard deviation, frequency, and percentages was used to analyze the respondents' (patients') awareness, acceptability and WTP for digital physiotherapy. Chi-square test was used to determine; the association between the WTP for digital physiotherapy and the socio-demographic factors, the association between acceptability for digital physiotherapy and the socio- demographic factors, and also the relationship between the WTP for digital physiotherapy and acceptability for digital physiotherapy. Alpha level was set at P < 0.05. The Statistical Package for the Social Sciences (SPSS) Version 16 (Chicago, IL) for Windows program was used to analyze the data.
| Results|| |
[Table 1] shows the socio-demographic characteristics of the respondents. The total number of respondents was 92 with a mean age of 52.40 ± 15.62 years.
The responses of respondents on the awareness of digital physiotherapy showed that, there was a high rate (91.3%) of “no awareness” about digital physiotherapy. 7.6% of those who were aware of digital physiotherapy got the information from the hospitals they patronize. 1.1% each of those who were aware of digital physiotherapy read about it from journals and from magazines, respectively. All (100%) of the respondents deny ever hearing about digital physiotherapy from advertisement while only four (4.3%) respondents heard about it from internet sources.
The degree of acceptability of digital physiotherapy is shown in [Table 2]. Sixty-six (71.7%) respondents agreed that they would benefit from digital physiotherapy. A greater percentage (83.7%) of the respondents accepted they would use the digital physiotherapy services if government hospitals or specialist clinics provide the services. Despite this degree of acceptability, some respondents had concerns on; privacy (18%), reliability (41%), accessibility (36%), cost (68%), and effectiveness (31%).
Acceptability score was created from each respondent's choice of options regarding digital physiotherapy. The minimum score was one (8.33% acceptability) and the maximum score was 11 (91.67% acceptability) from a total score of 12. The mean acceptability score was however 6.38 ± 1.79.
The levels of acceptability of digital physiotherapy with respect to the respondents are shown in [Figure 1]. It is pertinent to note that 62% of the respondents had moderate level of acceptability. The classification was based on an acceptability percentage computed from an acceptability score with which the respondents were grouped into <40%, 40%–60%, and >60% to depict low, moderate, and high acceptability for digital physiotherapy, respectively.
[Table 3] shows that the mean WTP amount for digital physiotherapy among the respondents was ₦1108 while the median amount was ₦700.
[Table 4] shows the association between WTP for digital physiotherapy and socio-demographic characteristics of the respondents. From the results, there was no significant association between WTP for digital physiotherapy and each of; age (χ2 = 2.901; P = 0.715), sex (χ2 = 0.103; P = 0.748), marital status (χ2 = 1.046; P = 0.790), occupation (χ2 = 3.759; P = 0.709), education (χ2 = 7.174; P = 0.208), and socio-economic status (χ2 = 0.489; P = 0.783).
|Table 4: The association between willingness-to-pay and sociodemographic factors and socioeconomic status|
Click here to view
[Table 5] shows the association between acceptability for digital physiotherapy and socio-demographic characteristics of the respondents. From the results, there was no significant association between acceptability for digital physiotherapy and each of: age (χ2 = 7.256; P = 0.701), sex (χ2 = 3.549; P = 0.170), marital status (χ2 = 7.197; P = 0.303), occupation (χ2 = 8.574; P = 0.739), education (χ2 = 8.245; P = 0.605), and socio-economic status (χ2 = 7.601; P = 0.107).
|Table 5: The association between acceptability for digital health and sociodemographic factors and socioeconomic status|
Click here to view
[Table 6] shows the association between the acceptability for digital physiotherapy and WTP for digital physiotherapy. The results show that there is no significant association between the level of acceptability for digital physiotherapy and the willingness to pay for digital physiotherapy (χ2 = 4.963; P = 0.084).
|Table 6: The association between acceptability for digital physiotherapy and willingness-to-pay for digital physiotherapy|
Click here to view
| Discussion|| |
This study evaluated the awareness, acceptability and the willingness to pay for digital physiotherapy among outpatients in Selected Hospitals in a South-Western State of Nigeria. The findings of this study show that there is a low awareness of digital physiotherapy among out-patients receiving physiotherapy in the selected hospitals. This finding may be attributed to the peculiarity of patients' demographics. For instance, a majority of the patients were in the 51–80 years of age category. It is commonly acknowledged that older individuals show low adjustment to the advent of new technologies compared to younger generations, either because they do not have the technological experience or because of their complacent status of the on-goings in their immediate environment. It is equally possible that the low level of awareness might not be unconnected to poor income, low level of education, geographical location, possible disabilities, as well as difficulties relating to the complexity of new technology. Other contributing factors to this low adjustment to new technologies are the lack of incentives, economical obstacles, digital skills, and appropriate training.
Nigeria is at its early stages of embracing technological advancements. The patients in this study expressed moderate level of acceptability for digital health. This indicates the patients were willing to accept new innovations that would grant them access to better health-care services. There are emerging studies on willingness of patients to accept and adopt new technology for the health care., However, acceptability of new technology for health care are skewed in favor of younger patients/clients. Rejection or low adoption of digital technologies for health care in older adults is implicated on many factors, and not limited to; fear of making mistakes and wider concerns about their social responsibility. Cajita et al., in a study on intention to use mHealth in older adults with heart failure acknowledged that, despite gains in the use of technology, older adults continue to lag behind younger people when it comes to technology adoption. There are pertinent issues in Nigeria which made patients skeptical regarding embracing this new innovation, one of which is unreliable electricity supply which can affect its reliability as expressed by 41% of the respondents in this study.
Despite the fact that there was an extremely low level of awareness about digital physiotherapy, a high number of patients (88.0%) were still willing to pay for digital physiotherapy. This is opposed to the study by Arize and Onwujekwe, where only 48.7% were willing to pay for telemedicine services. Furthermore, the patients in this study were willing to pay more (₦1108.70) for their treatment compared with the study by Arize and Onwujekwe, in which they were willing to pay (₦407.00). The maximum amount the patients in this study were willing to pay is ₦1108.70 ± 1238.46. The standard deviation being higher than the mean amount indicates that the amount the participants are willing to pay are widely spread out; the minimum amount they were willing to pay was ₦0 while the maximum was ₦6000. The median amount however was ₦700. Nigeria still operate out of pocket payment milieu for most of her citizens. As a result, patients usually pay directly for their treatment. That is not to acknowledge that some of the population are currently covered under the National Health Insurance Scheme (NHIS). Aregbeshola, in a study published in Lancet narrated that there is an over-reliance on out-of-pocket payments in Nigeria, despite having about 70% of its population living in poverty. Out-of-pocket payments can make households and individuals incur catastrophic health expenditure and this can exacerbate the level of poverty and negatively affects people's living standards and welfare. The study further highlights that >90% of the Nigerian population is uninsured in spite of the establishment of a NHIS, in 2006. Less than 5% of Nigerians in the formal sector are covered by the NHIS. Furthermore, only 3% of people in the informal sector are covered by voluntary private health insurance. Uninsured patients are at the mercy of a nonperforming health system. Health indicators in Nigeria have not changed substantially due to the nonresponsiveness of the health system to the needs and expectations of the population. Each public health facility in Nigeria seems to have autonomy on service charges. As a result, how much a patient pays varies from facility to facility. The participants in this study were willing to pay an average (mean willingness to pay) of ₦1108.70. This amount is about $3 (with an exchange rate of ₦363=$1) and it is a far departure from the amount paid for physical therapy session in the United States of America where the range is between $75 and $150 (Without Insurance) per session on average depending on the extent of the injury. With insurance, rates range from a $20 to $55 co-pay after you have paid your deductibles, and between $75 and $150 if you are paying without insurance. However, in a study by Mbada et al., the appalling health payments when compared with other countries, for example, the United States of America is because, in Nigeria, public spending per capita for health is between $2 and $5, which is awfully lower than $34 benchmark recommended by the WHO for low-and-middle income countries. Hence, an individual who is willing to procure digital therapy service for $3 is somewhat generous in an economy where the burden of paying for health care is particularly brutal for poor households.
Accepting digital physiotherapy is actually a difficult decision to take especially among people who have not tried it in time past. It is, however, not surprising that some of the patients expressed that they would only use digital technology as a complementary treatment or a follow-up to the normal routine conventional care and not as a replacement. These opinions were at variance with others who expressed that the traditional face-to-face interaction between the physiotherapist and the patient still works for them and they would not opt for a faceless alternative. This study, however, found out that majority of the respondents were willing to accept digital physiotherapy with just 13% of the respondents, signifying low level of acceptability, not willing to accept this service.
In this study, age, marital status, occupation, gender, education, and the socio-economic status were not found to be significant determinants for accepting the use of digital Physiotherapy services. These findings agree with a study by Liu et al., which concluded that socio-demographic characteristics were not significantly associated with the positive intention to use telerehabilitation. Affirming this, Cimperman et al., found that the level of education and gender variables had no significant influence on the intention to use telehealth.
This study also showed that variables such as occupation, sex, educational level, marital status, age, and socio-economic status were not found to be significant influences on WTP for digital Physiotherapy. Conversely, in the study by Arize and Onwujekwe, socio-economic status was a significant correlate of willingness to pay for telemedicine services. The impact of socio-economic status on WTP for digital Physiotherapy cannot be categorically confirmed as no standard tool was used to explore this construct other than biodata or pro forma used alongside the questionnaire. Literature revealed that, socio-economic status is one of the main factors that influenced WTP for health-care services.
This study found no significant association between the acceptability for digital physiotherapy and the willingness to pay for digital physiotherapy.
| Conclusion|| |
This study concludes that awareness of digital physiotherapy was low but there was a moderate to high level of acceptability and a high WTP for digital physiotherapy services.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Meskó B, Drobni Z, Bényei É, Gergely B, Győrffy Z. Digital health is a cultural transformation of traditional healthcare. Mhealth 2017;3:38.
Lupton D. Digital health now and in the future: Findings from a participatory design stakeholder workshop. Digit Health 2017;3:2055207617740018.
World Health Organization. Classification of Digital Health Interventions v1. 0: A Shared Language to Describe the Uses of Digital Technology for Health. WHO; 2018.
Hostetter M, Klein S, McCarthy D. Taking Digital Health to the Next Level. The commonw fund 2014: 94-100.
Dunphy E, Hamilton FL, Spasić I, Button K. Acceptability of a digital health intervention alongside physiotherapy to support patients following anterior cruciate ligament reconstruction. BMC Musculoskelet Disord 2017;18:471.
Steinhubl SR, Muse ED, Topol EJ. The emerging field of mobile health. Sci Transl Med 2015;7:283rv3.
Threapleton K, Drummond A, Standen P. Virtual rehabilitation: What are the practical barriers for home-based research? Digit Health 2016;2:2055207616641302.
Shenoy MP, Shenoy PD. Identifying the challenges and cost-effectiveness of telerehabilitation: A narrative review. J Clin Diagn Res 2018;12:12.
Lindquist AM, Johansson PE, Petersson GI, Saveman BI, Nilsson GC. The use of the Personal Digital Assistant (PDA) among personnel and students in health care: A review. J Med Internet Res 2008;10:e31.
Yang CH, Maher JP, Conroy DE. Acceptability of mobile health interventions to reduce inactivity-related health risk in central Pennsylvania adults. Prev Med Rep 2015;2:669-72.
Saposnik G, Teasell R, Mamdani M, Hall J, McIlroy W, Cheung D, et al
. Effectiveness of virtual reality using Wii gaming technology in stroke rehabilitation: A pilot randomized clinical trial and proof of principle. Stroke 2010;41:1477-84.
Levin MF, Weiss PL, Keshner EA. Emergence of virtual reality as a tool for upper limb rehabilitation: Incorporation of motor control and motor learning principles. Phys Ther 2015;95:415-25.
Merians AS, Jack D, Boian R, Tremaine M, Burdea GC, Adamovich SV, et al
. Virtual reality-augmented rehabilitation for patients following stroke. Phys Ther 2002;82:898-915.
Holden MK. Virtual environments for motor rehabilitation: Review. Cyberpsychol Behav 2005;8:187-211.
Ricker JH, Rosenthal M, Garay E, DeLuca J, Germain A, Abraham-Fuchs K, et al
. Telerehabilitation needs: A survey of persons with acquired brain injury. J Head Trauma Rehabil 2002;17:242-50.
Russell TG. Telerehabilitation: A coming of age. Aust J Physiother 2009;55:5-6.
Jafni TI, Bahari M, Ismail W, Radman A. Understanding the implementation of telerehabilitation at pre-implementation stage: A systematic literature review. Procedia Comput Sci 2017;124:452-60.
Camp PG. The 'wicked problem'of telerehabilitation: Considerations for planning the way forward. AIMS Med Sci 2018;5:357.
Hatzakis M Jr., Haselkorn J, Williams R, Turner A, Nichol P. Telemedicine and the delivery of health services to veterans with multiple sclerosis. J Rehabil Res Dev 2003;40:265-82.
Wootton R, Liu J, Bonnardot L. Assessing the quality of teleconsultations in a store-and-forward telemedicine network-long-term monitoring taking into account differences between cases. Front Public Health 2014;2:211.
Arize I, Onwujekwe O. Acceptability and willingness to pay for telemedicine services in Enugu state, southeast Nigeria. Digit Health 2017;3:2055207617715524.
Gücin NÖ, Berk ÖS. Technology acceptance in health care: An integrative review of predictive factors and intervention programs. Procedia Soc Behav Sci. 2015 Jul 3;195:1698-704.
Jeon EM, Seo HJ. Acceptability of Service Targets for ICT-Based Healthcare. Healthc Inform Res 2016;22:333-41.
Yao W, Chu CH, Li Z. The adoption and implementation of RFID technologies in healthcare: A literature review. J Med Syst 2012;36:3507-25.
Cajita MI, Hodgson NA, Budhathoki C, Han HR. Intention to Use mHealth in Older Adults With Heart Failure. J Cardiovasc Nurs 2017;32:E1-E7.
Aregbeshola BS. Out-of-pocket payments in Nigeria. Lancet 2016;387:2506.
National Bureau of Statistics. Nigeria Poverty Profile Report; 2020. Available from: http://www.nigeriastat.gov.ng
. [Last accessed on 2016 Apr 04].
Onoka CA, Onwujekwe OE, Uzochukwu BS, Ezumah NN. Promoting universal financial protection: Constraints and enabling factors in scaling-up coverage with social health insurance in Nigeria. Health Res Policy Syst 2013;11:20.
Mbada CE, Mamud SO, Odole AC, Omole JO, Oyewole OO, Ogundele AO, et al
. Development and clinimetric testing of willingness to pay tool for Physiotherapy. Phys Ther Rev 2019;24:134-42.
Onah MN, Govender V. Out-of-pocket payments, health care access and utilisation in south-eastern Nigeria: A gender perspective. PLoS One 2014;9:e93887.
Liu S, Yam CH, Huang OH, Griffiths SM. Willingness to pay for private primary care services in Hong Kong: Are elderly ready to move from the public sector? Health Policy Plan 2013;28:717-29.
Cimperman M, Brenčič MM, Trkman P, Stanonik Mde L. Older adults' perceptions of home telehealth services. Telemed J E Health 2013;19:786-90.
Fatoye F, Mbada C, Oluwatobi S, Odole A, Oyewole O, Ogundele A, et al. Pattern and determinants of willingness to pay for physiotherapy services. Eur J Physiother 2019;22:221-7.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]