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Changing the PublicPerception ofPhysiotherapeuticTreatmentLorraine Sheppard MBA aa Lecturer and Course-Co-ordinator,Bachelor Applied Science, School ofPhysiotherapy, University of South Australia,Aelaide, 5000, South AustraliaPublished online: 18 Oct 2008.

To cite this article: Lorraine Sheppard MBA (1995) Changing the PublicPerception of Physiotherapeutic Treatment, Health Marketing Quarterly, 12:2,77-96, DOI: 10.1300/J026v12n02_07

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Changing the Public Perception of Physiotherapeutic Treatment

Lorraine Sheppard, MBA

ABSTRACT. Market research was undertaken to establish the pub- lic perception of physiotherapy. Using this market research strategic recommendations for the future marketing of physiotherapy are made within the professional context. Marketing will be used to contribute to changing the public perception of physiotherapy.

The market research involved a qualitative study of five focus groups of the general public and one focus group of physiothera- pists. The responses from the focus groups were used to construct an appropriate questionnaire for the qualitative study. A random sample of 510 members of the general public were then surveyed. The market research results yielded the following key features:

The best known conditions treated by physiotherapists are musculoskeletal.The least known are women and children. Clientcentered care is sought 'The importance of location gives potential for physiotherapists to capitalise on tailoring to clients in theii area. Doctors are important for referral and communication about physiotherapy. Marketing should be used to inform doctors of what physiotherapy has to offer. A marketing orientation has begun within physiotherapy; how- ever, it must 'fit' the culture initially to be successful.

A marketing strategy should be developed on national, state and individual levels based on a strategic intent. At the state level, strate-

Lorraine Sheppard is Lecturer and Course Co-ordinator of the Bachelor of Applied Science (Physiotherapy) in the School of Physiotherapy, University of South Ausealia.

Send all correspondence to the School of Physiotherapy, University of South Australia, North Terrace, Adelaide, South Australia, 5000.

Financial assistance from the private practitioners group of the APA and Uni- versity of South Australia is gratefully achowledged.

Health Marketing Quarterly, Vol. 12(2) 1994 O 1994 by The Haworth Press, Inc. All righls reserved. 77

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78 IfEAL?7/ MARKlTING QUARTERLY

gies must be rcsponsive to area or regional nceds. Marketing needs to target identilied market segments such as workers compensation organisations. hdivldual physiotherapists must promote themselves within their region, particularly to doctors and clicnts with the use of relationship marketing. Informal presentations lo community groups and school studcnts about physioherapy will increase their profile.

INTRODUCTION

The purpose of this paper is to determine strategies which will ensure thatthe profession maintains the present high levels of professional service to the community. Planning based on the market research which could enhance the professional's ability to respond to the changing needs of the comrn&nity is discussed in the paper.

Given that physiothel.apy is a service within the health industry. not only do nppo~tuniries exist for it to be "marketed," but is necessary for a marketing orientation to be introduced in response to the increasing dynamism of the industry. Marketing can be de- f i e d as the "social and managerial process by which individuals and groups obtain what they need and want through creating, offering, and exchanging products of value with others" (Kotler, 1991: 4). Physiotherapy is a professional service which has particular im- plications for its marketing. Consequently, any marketing of phys- iotherapy must conform tdthe ethics1 and professional standards of registration and membership of a professional body.

The aim of this market research study was to assess the public's awareness of physiotherapy services. In doing so, the study also established the public's expectations of physiotherapy. By analys- ing these expectations it can be determined whether physiotherapy is meeting clients' needs. Finally, all the information was collated and used as a basis for formulating strategies which could be irnple- mented to successfully market physiotherapy.

The study involved two groups: the public and physiotherapists. The objectives of the study involving the public were:

To establish the level of public awareness of physiotherapy services To identify the sources of the public's awareness

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To determine why people use physiotherapy services To identify, in similar circumstances, what other health service providers people would consider consulting.

The objectives of the study involving physiotherapists were:

To identify the variety of physiotherapy services currently pro- vided to clients To establish the promotional activities which individual phys- iotherapists are using.

This paper considers market research information, providing an assessment of the "fit" of the physiotherapy industry within the health care environment by presenting:

The market research undertaken; its objectives and methodol- ogy. The results of the quantitative and qualitative study are detailed and analysed. An outline of strategic recommendations for the future mar- keting of physiotherapy within the health care environment, the physiotherapy industry and the professional context.

METHOD

The research was undertaken in three stages. Stage 1 involved qualitative research (subjective analysis) using a number of panels or focus groups from the general public. Stage 2 was quantitative research using a telephone questionnaire (survey research). Stage 3 involved qualitative research using a focus group of physiothera- pists.

Stage 1-Focus Groups

Focus group research was used as a qualitative technique which involves a small number of people who discuss selected topics with a moderator in order to provide an in-depth, subjective understand- ing of the consumer. The moderator encourages open discussion,

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80 HEALTH MARKETING QUAR7'ERLY

hoping that group dynamics will reveal deep feelings and thoughts. At the same time, the moderator "focuses" the discussion giving the exercise the name "focus-group interviewing" (Calder 1977; Goldman 1962; Kams et al. 1988; Kotler 1991; Morgan 1986; Schoenfield 1988; Wallace 1984; Welch 1985). The focus groups elicit different attitudes which were revealed in the way participants both asked and answered questions. The participants also gave rea- sons for their answers to quantitative survey questions. In this re- spect, focus groups elicit the language of the consumer, making it easier to detect if the questions are not understood. Focus group research with small samples is preliminary and cannot be general- ised without further research.

The five focus groups were organised to stimulate discussion about physiotherapy. Clear objectives were chosen for the focus groups:

To examine issues relating to the awareness of physiotherapy To develop a meaningful and relevant questionnaire for the quantitative phase of the research.

Five focus groups were chosen to represent a cross section of views. Demographics of gender and age weE selected as the basis for some groups, while a psychographic segment of sports people was also used. Psychographic segments are based on attitude, belief .or lifestyle. Groups were not selected on the basis of the level of usage of physio- therapy services in order to avoid the discussion concentrating on the condition which required physiotherapy treatment.

.The five focus group meetings were conducted in South Austra- lia, and included:

Sports people Young people, between 18 to 30 years of age Older people, over 55 years of age Male group Female group.

The mean group size was eight (range 6 to 10). Each group was videotaped in order to enable the moderator to pay attention to the group and later study the video for any missed information. The

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Lorraine Sheppard 81

responses from the focus groups were used to construct the ques- tionnaire.

Stage 2-Questionmire

Both open and closed questions were used. The open questions had common answers coded in order to aid the interviewer. These were developed from the focus groups and the piloting of the ques- tionnaire; however, they were not used to prompt respondents. The closed questions had a full set of alternatives which were read to the respondents (i.e., strongly agree through to strongly disagree). "Can't say" was given as a legitimate choice, as part of an attitude scale. The total questionnaire was designed to be no longer than ten minutes to avoid the development of both fatigue and rapport. The questions were set out in a specific order so as to avoid the context effects of consistency, contrast and salience whilst maintaining a logical flow (Bradbum and Mason 1964; Kotler and Clarke 1987; Kraut et al. 1975; Shuman and Presser 1981; Tourangeau et al. 1989).

The draft questionnaire was piloted with individual personal in- terviews of 10 members of the general public in order to check their ability to understand the questionnaire. The questionnaire was fur- ther piloted with telephone interviews of 25 members of the general public to ensure flow and timing of the s w e y instrument.

The sample for the telephone questionnaire was generated by random digit dialling in the evenings during April 1992, over a period of 7 days, in order to achieve a representative sample from each state's population. It should be remembered that this method introduces a bias as only those people with a telephone could be included in the sample. The sample population used can been seen in Table 1. The sample size of 510 people can only be representative of the public's perception of physiotherapy.

Stage 3-Research of Physiotherapists

A focus group of 10 physiotherapists was organised with repre- sentatives from various specialties and areas of employment. The method was the same as for the general public focus group. How-

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HEALTH MARKETING QUARTERLY

TABLE 1. Respondents to the public questionnaire

STATE Queensland

New South Wales

Victoria

South Australia

Western Australia

Tasmania

Northern Territory

Total

LOCATION Brisbane

Regional Country

Sydney

Regional Country

Melbourne

Regional Country

Adelaide Regional Country Perth

Regional Country

NUMBER OF RESPONDENTS 37

46 112

72

98

37

32 12

33

13

14

4

510

ever, there was no quantitative survey undertaken of the physiother- apists as it was felt that this professional group is most effectively interviewed by focus group.

RESULTS AND DISCUSSION

Public Questionnaire

The results of the public survey are considered in line with the research's objectives and in the following broad categories:

Public awareness of physiotherapy services Source of the public's awareness Reasons people use physiotherapy

The most significant points will now be presented under each objective. The total number of people telephoned throughout Aus- tralia was 531.

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Plrhlic Awareness of Physiotherapy Service5

The public was generally aware of massage, heat, exercise, ma- nipulation and massage treatments provided by physiotherapy (see Figure 1). Low responses were recorded for hydrotherapy and pres- sure points.

The responses for conditions and treatments associated with physiotherapy did not vary significantly with age, location (city or country) or gender (p > . lo).

There was a reasonably high public awareness .of the musculo- skeletal conditions treated by physiotherapists, which includes muscles. sports. joints and accident rehabilitation (see Figure 2). Musculoskeletal conditions are expected to increase in the future with the increase in chronic conditions, presenting growth opportu- nities for physiotherapy.

ln contrast. there was very low public awareness of the treatment provided by physiotherapists for women's and children's condi- tions, including antenatal care. Such low awareness of women's and children's conditions presents considerable potential for growth.

Sources of the P~thlic's Awareness

To identify the source of the public's awareness, the survey popu- lation was asked how they would choose a physiotherapist. A high proportion (59%) of the total survey sample had used a physiothera- pist. Those who had visited a physiotherapist provided slightly different reasons for their choice (Table 2) from those who had not, assuming they were to choose a physiotherapist (Table 3).

The percentage responses in Tables 2 and 3 for advertisement are notable. It can be concluded that advertising appears to raise aware- ness of physiotherapy (that is, 29% would select a physiotherapists based on an advertisement, if they had never been). However, of those people who have actually attended a physiotherapist, very few (1%) relied on advertising to make their choice. It seems that adver- tising is not resulting in decision making, merely raising awareness. Doctors' and personal recommendations are often used as a means of selecting a therapist which presents several avenues of commu- nication that should be developed.

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PERCENTAGE RESPONSE

- - N N w O P P m o m o m o m o m o m o

children --

-- women 1 --

-- don't know

--

accident rehabllltat~on

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86 llEALTH MMKErING QUARTERLY

TABLE 2. Of those who attended a physiotherapist, how they chose their therapist

RESPONSE PER CENT FREQUENCY Personal recommendation 22 47

Doctors referral 65 135

Advertisement 29 60

Health centre 9 19

No choice 3 6

Other 1 3

Can't say 2 4

TABLE 3. Of those who had never attended a physiotherapist, how would they choose a therapist

RESPONSE PER CENT Personal recommendation 22 Doctors referral 65

Advertisement 29

Health centre 9

No choice 3

Other 1 Can't say 2

Multiple responses, total exceeds 100 per cent

FREQUENCY 47

135

60

19

6

3 A

Reasons People Use Physiotherapy

In the main, the reasons were related to musculoskeletal injuries with only 11% considering their visit was a result of an unknown cause (see Table 4). In comparison, of those who had never been to a physiotherapist, over 90% said they never needed physiotherapy. This may indicate problems of self diagnosis and presents an oppor- tunity to increase client numbers by education of situations in which physiotherapy is required.

An insight into why people choose physiotherapy is provided in

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Lorraine Sheppard 87

their expectations on visiting a physiotherapist. These expectations are outlihed in Table 5.

Changing public expectations are apparent with an increasing demand for more information and explanation from professionals. Control over treatment is sought as the public expect exercises and preventative advice, such as back care classes. Location is impor- tant and presents an opportunity for physiotherapists to be in tune with their locality.

The public desire to have more control over treatment has in- fluenced clients. They now want to know as early as possible how many treatments they will require. Some confusion is apparent as to whether a physiotherapist is more expensive than a general practi- tioner, with 43% agreeing, 24% disagreeing and 32% could not say.

A common complaint raised in the focus groups was that physio- therapists requested that the client return for treatment too often. This was also reinforced in the telephone survey. However, when

TABLE 4. Client communication about physiotherapy treatment

RESPONSE PER CENT Work colleagues 13 Personal friends 39 Doctor 35 Family 44 Sports friends 8 Husbandlwifelpartner 20 No one 13 Other 4 Multiple responses, total exceeds 100'per cent

FREQUENCY 40 116 105 132 25 59 39 13

TABLE 5. Of those who had visited a physiotherapist, some of their reasons

REASONS Sporting injury Work injury Other accidents Unknown cause

PER CENT FREQUENCY 25 74 23 69 16 48 11 33

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88 HEALTH MARKDING QUARTERLY

asked if they would know when to stop going, 52% said yes and 42% said no. This again raises the issue of the lack of self diagnosis skills amongst the public. A large percentage seem to rely on the practitioner's judgement to assess their progress or possible prog- ress. However, in the focus groups, some people preferred chiro- practors over physiotherapists as they set out the number of visits1 treatments required at the commencement of treatment. Given the demand by clients for more information and control, it seems desir- able to indicate as early as possible the likely number of visits and physiotherapists should strive to achieve this wherever possible.

Physiotherapist Focus Group

The focus group expressed the view that physiotherapists gener- ally promote themselves to doctors in their practice locality or their specialty area. Some physiotherapists see the benefit of 'marketing' but do not see it as "for them."

A community based representation for physiotherapy is sought, including a more publicly accessible professional association. Com- munity initiatives should be joined by physiotherapists, such as breast screening incorporating advice on back care. In addition. working with school students should be pursued, such as sports trainer courses run by physiotherapists.

The group disliked the idea of reminder cards or check up ap- pointments made for the future. They expressed a reluctance to charge for their services, which may be a response to the expected equity of access to health care.

The individual physiotherapist promotes h m e r s e l f by the "job they do" and the personal recommendations this brings. The con- sensus of the group was the importance of relationship building with medical students and with doctors in hospitals where inforrna- tion of the work of physiotherapists could be conveyed. Physiother- apists wishing to promote themselves are now being called upon to speak to large groups, such as Rotary luncheons. Therefore, work-

- - ~

shops in presentation skills and dealing with media were requested. The physiotherapists in the group recognised the need for mar-

keting in their own practices and for the profession as a whole. As the competitive environment increases, the acceptance of marketing techniques by the profession will increase.

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Lorraine Skeppard 59

A future strategy which promotes physiotherapy's unique attri- butes will ensure the maintenance and further growth of the physio- therapy. To differentiate physiotherapy from its competitors whilst increasing awareness of the services it can provide, .marketing needs to be used. Marketing can bridge an organisation to its envi- ronment. Physiotherapy can use marketing but this must be consis- tent with the professional setting and culture of physiotherapy.

STRATEGIC RECOMMENDATIONS

The following recommendations represent a broad approach and in no way give a detailed marketing plan. This would not be ap- propriate especially given the diverse nature of the physiotherapy industry.

A national strategy is proposed in order to provide a national focus and overview to future directions for physiotherapy. The na- tional framework would give direction and support to state branches and individual physiotherapists. In particular, the competitive and diverse nature of the physiotherapy industry requires marketing strategies at the following levels:

National State Individual.

National

The national framework for strategy requires a strategic intent. This gives clarity of direction, envisions a desired leadership posi- tion and establishes the criterion for the profession to chart its progress. A strategic intent also implies a "stretch" for the profes- I

sion, forcing it to be more inventive and make the most of limited resources (Hamel and Prahalad 1989). The national marketing strat- egy would also involve the formulation and articulation of long term marketing objectives and strategies, promoting all aspects of physiotherapy.

Traditionally, market segmentation has been used to determine which groups should be targeted for marketing. However, markets

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90 HEALTH MARKETING QUARTERLY

fragment and proliferate with market boundaries changing ever more quickly. Targets are elusive and capture is at best temporary (Prahalad and Hamel 1990). Owning or dominating in any of these segments is therefore more difficult and less valuable (Stalk et al. 1992). Quality assurance programs can ensure quality, but cost and quality standards provide minimum hurdles for continued competi- tion since competitors can readily match these standards. There is therefore a need to develop unique attributes that differentiate phys- iotherapy from its competitors. Within this context a portfolio of competencies should be identified to form the core of a strategic intent.

The core competencies must be able to provide potential access to a wide variety of markets and make a significant contribution to the perceived client benefits. In the long run, it has been argued that competitiveness comes from building core competencies that span unanticipated products/se~ices (Prahalad and Hamel 1990; Beck- ham 1991). Consequently, the selection of a core competency should be one that is difficult for competitors to imitate (Prahalad and Hamel 1990). In particular, it should enable capabilities across the physiotherapy industry to be exploited, whilst focusing on spe- cific strengths of the industry, for example specialist training in musculoskeletal injuries.

Current core competencies can be identified from market re- search include:

Client centered service Re-education of movement and function through life Orthodox medical approach in line with doctors Musculoskeletal and sports injury management Aged care Women's andchildren's care Matching service provision to regional or area health needs.

Thus, physiotherapy's key core competency could be client-cen- tered service.

Strategic Architecture

The implementation of this strategic framework requires a strate- gic architecture. A strategic architecture provides the "systems" to

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Lorraine Slreppard 91

support any competency based approach. This could be initiated nationally and establishes the objectives for competency building and exploitation. A strategic architecture will identify which com- petencies to build and how best to support them making resource allocation priorities transparent to the entire organisation. It in- cludes an administrative and communication infrastructure, the in- tegration of human resource management and the creation of a managerial culture with a willingness to think long term (Prahalad and Hamel 1990).

Crucial to this approach will be "relationship marketing." While the identified core competency, clientcentered service, must be pervasive throughout all activities undertaken, relationship market- ing aims to develop long term trust in a "win-win" relationship in particular with clients, doctors and politicians. This is accomplished by promising and delivering high quality, good service at fair prices to the client. The two parties grow more trusting, more knowledge- able and more interested in helping each other (Kotler 1991; Uling- worth 1991). However if clients' needs change, they will be more influenced by the availability of substitute services, for example chiropractors. Competitive advantages come from understanding and anticipating this growing client experience effect and in design- ing strategies which adjust to the market changes (DeBruicker and Summer 1985).

A national strategy must also address the national issues of repre- sentation to federal politicians and responses to federal issues, such as involvement in the export of physiotherapy clinical and educa- tion specialties.

Objectives for a national strategy could include:

Greater recognition of physiotherapy care in the women's and children's areas Increased market share for physiotherapy of the expenditure on health care provided by private and public bodies Closer affiliation with doctors.

These objectives can be measured by using surveys to reassess recognition levels, reviewing health industry data in order to evalu- ate market share, and using surveys to observe the affiliation of physiotherapy with doctors.

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92 . NEAL.TH MARKETING QUARTERLY

The national strategy would therefore include:

Development of a strategic intent nationally Promotion of a portfolio of core competencies Establishment of a strategic architecture for successful imple- mentation and evaluation of the national strategy Targeting of federal politicians

Within this national framework both state and individual strate- gies can be developed.

State

Working within the national framework, state strategies can be developed for the long and short term growth of physiotherapy markets. It must be noted that an overemphasis on marketing is not acceptable within the health care environment. Therefore, there is a need to educate of physiotherapists in marketing within the health care context would better support these strategies.

In the short term, target marketing can be used, for example to increase the awareness of women's health care.

Target areas currently identified include:

Musculoskeletal areas Cardiorespiratory physiotherapy services Women's health An ageing population with increased likelihood of strokes and dementia offers opportunities for growth in neurological phys- iotherapy, as these services are lesser known Children's conditions State politicians State funding bodies, such as workers compensation organisa- tions State branches of the Australian Medical Association (AMA).

However, within these target areas education on self diagnosis of when to choose physiotherapy is required to encourage client use of services. Preventative programs should also be introduced, for ex- ample physical education programs in schools which include back education.

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In the long terrn, the portfolio of core competencies must be promoted. The national strategic architecture, if appropriately de- signed and implemented, will support and facilitate this approach. The aim should be for specialist physiotherapists to be identified with a view to developing a coherent team of state based physio- therapists.

Individual

Within the context of the national and state strategic architecture, individual physiotherapists will need to be responsi;e to their local- ity and use relationship marketing to build relationships with their clients and referring doctors.

In the short terrn, as location is a major factor in the choice of physiotherapist. local environmental scanning is required to estab- lish the health needs of an area. Client centered care is wanted and relationship marketing enables understanding and responsiveness to clients' needs. Client information such as an outline of the total number of treatments and preventative advice with clear explana- tion of the costs of care support this approach. Physiotherapists could give consideration to the use of "reminder cards," which were disliked by physiotherapists but accepted by patients, particu- larly from chiropractors and dentists.

Physiotherapy services offered can then be tailored to the local needs. Working within the locality, relationships with referring doc- tors and clients can be developed. Doctors are a primary source of client referral and relationship building will facilitate this.

In the long term, the development of core competencies to be promoted in line with area health needs is required. By calling upon the physiotherapy specialists identified for support, the attributes that differentiate physiotherapy from its competitors can be pro- moted at the local or individual physiotherapy level.

CONCLUSION

The level of public awareness of physiotherapy is high. The market research results yield the following key features in the con- text of the health care environment and the physiotherapy industry:

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94 / - / & N T H MARKETING QUARTERLY

The best known conditions treated by physiotherapists were musculoskeletal. The least known were women and children. Client-centered care is sought. The importance of location gives potential for physiotherapists to capitalise on changes to area health management. Doctors are important for referral and communication about physiotherapy. Marketing can be used to inform doctors of what physiotherapy has to offer. A marketing orientation has begun within physiotherapy; however, it must "fit" the culture initially to be successful. The health care environment is dynamic and the alternative health service providers are threatening physiotherapy mar- kets. Marketing can differentiate the unique attributes of phys- iotherapy from its competitors.

The continued maintenance and growth of physiotherapy there- fore requires a marketing strategy which recognises and responds to this changing environment. The appropriate marketing strategy should focus on the physiotherapy profession's core competencies. This national strategic intent needs to be developed in association with a supportive strategic architecture. A coordinated national ap- proach will provide the framework for the development of state and individual marketing plans.

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