Attitude towards tele rehabilitation-based therapy services and its associated factors among health professional working in specialized teaching hospitals in Amhara region, Northwest Ethiopia,2021


 Background

Tele-rehabilitation is part of Tele-health (TH) which provides a rehabilitation service at a distance through telecommunication technology. Lack of enough trained professionals, lack of access, transportation cost, long waiting time, and difficulty of mobility to reach rehabilitation services are problems faced during face-to-face rehabilitation services. The significance of this study is to assess the attitudes and associated factors of health professionals about TR services.
Method

 An institutional-based cross-sectional quantitative study design was conducted among 408 participants from March to April 2021. Study units were selected by using a simple random sampling technique. Epi-data 3.1 versions were used to enter data, while SPSS version 20 was used to conduct analysis. A bivariable and multivariable logistic regression was used to determine factors associated with the attitude of health professionals towards tele-rehabilitation.
Result

A total of 408 participants responded to the 423 survey questionnaires distributed. A response rate of 96.45 % was achieved for this study. Out of the 408 respondent’s majority, 285(69.9%) of health professionals had good attitude towards tele rehabilitation-based treatment services. Among the factors good knowledge of tele rehabilitation AOR 1.76(95%CI: 1.078, 2.879), digitally literate AOR 1.74 (95%CI: 1.028, 2.954), perception on security and privacy AOR 0.56(95%CI: 0.333, 0.944), and owns smart mobile phone AOR 1.9 (95%CI: 1.007, 3.781) were significantly associated with attitude of tele rehabilitation.
Conclusion

The majority of the respondents had a good attitude towards tele rehabilitation services. Having own mobile, knowledge towards tele rehabilitation, digital literacy, perception on security and privacy to rehabilitation was found to be the most important determinant factor for the attitude of health professionals towards tele rehabilitation. As a result, the government and other responsible entities should consider enacting systems and strategies to encourage the use of mobile technologies for the management of disability and chronic diseases.

with some form of disability due to different complication(6). Around 80 million people are disabled in Africa (7). whereas, in Ethiopia it accounts for nine percent of the total population(8). Around 84% are assumed to live in rural areas and have limited access to basic services (9). The scarcity of medical specialists, the inadequate transportation infrastructure and due to the di culty of mobility in reaching rehabilitation center makes it even more di cult to provide healthcare in remote and rural areas (10).a study conducted in Saudi Arabia (11), Pakistan (12) and Nigeria(3) shows using tele rehabilitation for patients who have disability is the best service method. This study will help the specialized teaching hospital better understanding how to use information technology to help people with disability. This nding will serve as a basis for policymakers, researchers, and anyone interested in TR or disability patient care to build effective methods. Therefore, this study assesses the attitudes and associated factors of health professionals about TR services.

Study design and setting
An institutional-based cross-sectional quantitative study design was conducted in the Amhara region, north west Ethiopia. The Amhara region is located in the North-Western part of Ethiopia. It has 10 administrative zones, one special zone, 181 woredas, and 78 urban centers. The capital city of the State of Amhara is Bahir-Dar. It has around 85 hospitals (2 specialized teaching referral hospitals, 6 referral hospitals, more than 4 general hospitals, and around 73 primary hospitals), more than 850 health centers, and around 3,350 health posts. Currently, there were more than ve rehabilitation center o ces in teaching, referrals, and general hospitals of the region. These studies were conducted at specialized teaching hospitals namely the University of Gondar and Tibebe Ghion Specialized teaching referral hospitals. Each hospital is estimated to serve ve million people in their catchment area. More than two thousand health professionals are working in these two hospitals.

Study population and data collection
All health professionals who were currently working at Amhara region specialized teaching referral hospitals were the study population, the sample size was determined based on the assumption of single population proportion formula. A strati ed sampling procedure was used by considering professions as strata. Finally, participants were chosen from each profession using a simple random sampling technique. In this Study attitude was measured by a ve-point Likert scale of attitude question which categorized into good and poor depending on the threshold which was computed using the demarcation threshold formula. Self-administered pretested structured questionnaires adapted and modi ed from different kinds of literature. Data was collected by four trained data facilitators guided by two supervisors. To control the quality of data training was given for the data facilitator for one day.

Statistical data analysis
The data was cleaned to check for errors and missed values and corrected accordingly. The data entry form was prepared with Epi-data 3.1 versions and analyses were conducted using SPSS version 20. The binary logistic regression method was used to identify independent variables associated with dependent Variables having a p-value of <0.2 and multivariate analysis were conducted to show the relationship between multiple independent variables and dependent variables. P-value lees than or equal to 0.05 was taken as a cut of value to be signi cant. Adjusted odds ratio (AOR) with a 95% con dence interval (CI) was used to make interpretations of the result. Ethics approval and consent to participate Ethical clearance was obtained from the ethical review board institute of public health at the University of Gondar. Written consent was taken from university of Gondar and Tibebe Ghion teaching specialized hospital.

Results
Socio-demographic characteristics of health professionals in Amhara Region Teaching hospital, 2021 A total of 408 health professionals completed the survey questionnaires with a response rate of 96.5 %. The majority (73.3%) of the non-respondents were from the University of Gondar teaching hospital. In this study, the majority of the participants were males, 259(63.5%). The mean age was 27.85+_3.951 SD years and the majority of respondents were less than 30 years of age. Regarding to educational level, the majority (81.1%) of the participants were bachelor's degrees and below. Majority 69.9% of the participants have working experience of less than or equal to four years (Table 1) Access to basic technology among health professional in Amhara Region Teaching Specialized Hospital, 2021 The majority of 288 (70.6%) of health professionals have a personal computer. However, less than 50% of health professionals indicated their personal computers had internet capabilities. Regarding smartphones, more than 86% of health professionals have their own smartphones. Furthermore, from the participants, only 35 (8.6%) of health professionals indicated that they did not have a social media account. (Table 2) Knowledge of Health professionals towards Tele-rehabilitation The majority 261(64%) of health professionals had good knowledge of Tele-rehabilitation-based therapy services. Among the respondents, 243(64.3%) were heard about Tele rehabilitation-based therapy services ( gure 1).
Organizational related variable on attitudes of HP towards Tele rehabilitation Of the total respondents, 160(39.2%) of the study participants were took computer-related training. More than half 217(53.2%) of the health professionals had internet access in the o ce or clinical practice (Table 3) Technological related variable of health professional Among the total of the respondents, 241(59.1%) have high digital literacy. More than half 210(51.5%) of health professionals had negative perceptions of the security and privacy of Tele rehabilitation technology ( gure 2).

Attitude of health professionals towards Tele-rehabilitation
From the total of 408 respondent's majority, 285(69.9%) of health professionals had good attitude towards Tele rehabilitation-based treatment services ( gure 3) Factors associated with the attitude of health professionals towards Tele-rehabilitation-based therapy services. In a Bivariate analysis educational level, profession, experience, own computer, own smartphone, computerrelated training, IT support staff in the organization, internet access in an organization, knowledge towards telerehabilitation, digital literacy, perception on security and privacy, were found signi cantly associated with attitudes towards tele rehabilitation at a p-value<0.2. In multivariate analysis knowledge towards telerehabilitation, digital literacy, perception of security and privacy on tele rehabilitation, and own smart phone were signi cantly associated with attitudes towards tele rehabilitation at P-value<0.05 (table 4).
With respect to knowledge respondents who have good knowledge towards tele rehabilitation-based therapy services were 1.7 (AOR: 1.761(1.078, 2.879) times higher to have a good attitude on tele rehabilitation-based therapy services than those who have poor knowledge about TR services.
Participants who have high digital literacy were 1.7 (AOR: 1.743(1.028, 2.954), times more likely to have good attitudes towards tele-rehabilitation-based therapy services than those who did not have digital literacy. Health professionals who had a negative perception of security and privacy about tele rehabilitation-based treatment services were 44% (AOR: 0.561(95%CI: 0.333, 0.944), less likely to have good attitudes towards tele rehabilitation than those who have a positive perception of privacy and security towards tele rehabilitation services. Respondents who have their smartphones were 1.9(AOR: 1.951(95%CI: 1.007, 3.781) times higher to have a good attitude towards tele rehabilitation-based therapy services than those who did not have smartphones or access to mobile phones. (Table 4)

Discussion
This study aimed to assess the attitude and associated factors of health professionals towards tele rehabilitation for a disability, chronic disease management, and for diseases that require physical distancing.
Our ndings indicated that the overall attitudes of health professionals toward TR were good, with 69.9% of health professionals had to have a good attitude (CI: 65.38-74.32). This nding is following the study conducted in Tehran majority of health care providers had a positive attitude towards Tele rehabilitation (13).
Also similar to the study in Saudi Arabia on tele rehabilitation (11). In the same way, studies conducted in India reported that the attitude of healthcare providers was good, such as a survey conducted on the attitude towards tele-dentistry shows 70% of healthcare providers had a positive attitude (14), a similar study on postgraduate dental students shows 71.1% of respondents had positive attitudes (15), a survey on the attitude of telemedicine reported that 70% of health professional have a favorable attitude towards telemedicine (16) And a study on attitude towards a mobile-based exercise majority of care provider had a good attitude (17). Likewise, a survey that assesses the attitude towards healthcare ICT and home follow up in Sweden, indicated that 70% of health professionals have a positive attitude (18). On the other hand, this nding is slightly lower than the study conducted in Germany on app-based therapy among health professionals (77.2%) of participants who had a good attitude (19). Similarly, slightly higher ndings were reported in the study conducted in Egypt on telemedicine where 75% of dermatologists have a good attitude towards telemedicine (20). Also, a study in Libya was higher than this study indicated (82%) of health professionals had a good attitude to telemedicine during covid 19 pandemics(21). This discrepancy might be due to technological infrastructure, training towards e-health, low attention to e-health, and management support. But, this nding is better compared to a study conducted in Ethiopia on telemedicine which indicated, 64% of health professionals have a good attitude (22). The possible explanation is due to the study period (the study was conducted 4 years ago). Further, this could be due to taking courses towards e-health and telemedicine for clinical staff and also graduates of clinical elds and due to studies conducted about telemedicine and another e-health program.
In this nding, knowledge of tele rehabilitation was signi cantly associated with the attitude of tele rehabilitation (AOR: 1.761(95%CI: 1.078, 2.879). Health professional who had good knowledge of TR were a positive attitude towards TR services. This is in line with other studies which indicate knowledge towards tele rehabilitation could have a positive association with having a good attitude. (23). This nding is supported by the study conducted in Saudi Arabia on knowledge and attitudes towards tele rehabilitation indicates that lack of knowledge of tele rehabilitation is limiting the use of tele rehabilitation(24). These ndings is similar to those of Pakistan who maintain that lack of ICT knowledge among practitioners and concerns around patient con dentiality were among the factors that limit the practice of tele rehabilitation (12). This study is consistent with the study conducted in Tehran (13) and Saudi Arabia (25).
The most important technology to address tele rehabilitation services is the mobile phone. In this study, the majority of health professionals have mobile phone access and own smartphones, which were signi cantly associated with health professionals' attitudes toward tele rehabilitation (AOR: 1.951). (95 percent CI: 1.007, 3.781). Participants who own smartphones were 1.9 times more likely to have a good attitude towards telerehabilitation than those who didn't have smartphones. This nding was consistent with the study conducted in In this nding perception of security and privacy towards tele rehabilitation is signi cantly associated with attitudes towards tele rehabilitation (AOR: 0.561(955CI:0.333, 0.944). More than half of health professionals (51.5%) had a negative perception of privacy and security of information about tele rehabilitation technologybased therapy services. Health professionals who had a negative perception of security and privacy towards tele rehabilitation are 44% less likely than those who had positive perceptions of security and privacy towards Tele rehabilitation. this nding is supported by the study conducted in Saudi Arabia on Tele rehabilitation among health care providers indicated the majority of the participants considered that patient data security and patient privacy are at risk is associated with Tele-rehabilitation services (24) (25). In the other comparison, this study is similar to the study in Germany on app-based therapy. (19) Australia (29) and Pakistan (12).

Declarations Ethics approval and consent to participate
Ethical approval to conduct the study was obtained from the University of Gondar ethical review board.
Communication with the different o cial administrators of each teaching hospital was made through a formal letter obtained from the University of Gondar. The purposes and data privacy issues of the study were enlightened to every individual study participant and their written informed consent was taken before the study.
We con rm that all methods were carried out in accordance with the relevant guidelines and regulations.

Consent for publication
Not applicable.

Availability of data and materials
Full data set and materials pertaining to this study can be obtained from corresponding author on reasonable sectional study. International journal of telemedicine and applications. 2019;2019.   Technological factors towards Tele rehabilitation among health professional in Amhara region specialized teaching Hospital, 2021