Abstract
Background
Direct access to physical therapy (DAPT) services has attracted global attention for its potential to promote healthcare coverage, access, and equity. This study investigated physical therapists’ opinions on DAPT practice, including awareness, perceived barriers, potential benefits, and implications for healthcare.
Methods
A cross-sectional study was used to survey 137 physical therapists from governmental, semi-governmental, and private centers. The Bury and Stokes tool was used to evaluate the DAPT opinions that were originally assessed in the views of World Confederation for Physical Therapy (WCPT) members on DAPT policy. The link to the questionnaire and informed consent was emailed to the physiotherapists. Data was reported in percentages and means as appropriate. Mann‒Whitney U-test and the Kruskal‒Wallis test were employed to explore associations between variables.
Results
The physiotherapists demonstrated good theoretical knowledge (65.7%) and understanding of DAPT concepts (73%). The overall awareness score was 2.46 ± 0.48 out of 3. Many supported (80.3%) and were willing to practice DAPT (77.7%). Out of a total mean score of 5, major concerns include physicians’ views score (3.32 ± 1.12), lack of evidence-based practices (3.07 ± 1.06), lack of professional competencies (3.01 ± 1.06), and payment models (3.2 ± 1.11). The documented advantages encompass enhanced patient satisfaction (4.19 ± 0.79), expedited services (4.32 ± 0.75), and elevated professional standing (4.33 ± 0.74). Senior practitioners demonstrated a higher level of awareness in comparison to their junior colleagues (score: 2.4 vs 2.6; p=0.004). Additionally, physiotherapists with over 25 years of clinical experience recognized the benefits of direct access over their counterparts with lesser experience (> 25 years’ experience median score 4.5; vs median scores < 4 for all lesser experience groups; p<0.003).
Conclusion
This study emphasizes physiotherapists’ opinions and positive attitudes regarding the DAPT policy implementation in Saudi Arabia. Nevertheless, addressing the challenges identified through education, advocacy, policy adjustments, and collaboration between stakeholders can enhance the accessibility, quality, and overall delivery of physiotherapy services.
Keywords: direct access, perspectives, physical therapy, policy implementation, Saudi Arabia
Introduction
The twentieth century witnessed a growing recognition and appreciation of physical therapists as the principal contact for patient care, independent of referrals from medical doctors, a concept termed “direct access to physical therapy”.1 The World Confederation for Physical Therapy (WCPT) introduced the term “direct access” to describe the policy.2 By definition, “Direct access physical therapy (DAPT) refers to the ability of patients to seek physical therapy evaluation and treatment without the prerequisite of a physician’s referral”.3 Should this policy be implemented, it has the potential to significantly transform healthcare by providing professional autonomy to physiotherapists that may alleviate some of the responsibilities of primary care physicians. This strategy prioritizes patient empowerment, allowing individuals to take charge of their healthcare choices and reduces prolonged waiting periods. Consequently, this fosters greater equity in healthcare delivery and promotes early intervention, thereby mitigating the advancement of health issues and decreasing the necessity for more intricate and resource-demanding treatments.
Many studies have highlighted the positive impact of direct access on patient outcomes and the healthcare system.4–6 Direct access policies for physiotherapy services have been adopted by countries such as the Netherlands, Canada, some states of the United States of America, Australia, and New Zealand, as well as some zones of the United Kingdom’s National Health Services.7–9 Studies conducted in the United States have demonstrated the cost-effectiveness and improved functional outcomes associated with DAPT compared with traditional physician-first access models.10 But despite the potential benefits, evidence from multiple studies and randomized trials has identified several factors that may hinder the successful implementation of DAPT.11,12 These include inadequate diagnostic decisions by physiotherapists, concerns from insurance companies regarding increased reimbursement costs due to easier access to services, lack of evidence-based practices, restrictive hospital policies, and varying perceptions among stakeholders.11–13
The current policy in Saudi Arabia requires a physician referral to access physiotherapy services. Most physiotherapy services still require referral pathways through physicians, especially within government hospitals and regulated health systems. Given the need to implement a model of healthcare delivery that enables patients to directly seek physiotherapy services without prior physician referral in Saudi Arabia, it is necessary to assess the perspectives of physiotherapists regarding DAPT. Therefore, we investigated the awareness and perceptions of physiotherapists with the following objectives: understanding the level of awareness of DAPT among physiotherapy practitioners in Saudi Arabia, investigating the perceived barriers and obstacles hindering the implementation of DAPT in the healthcare system, and assessing the expectations of physiotherapy practitioners towards DAPT, including its potential benefits.
The results of this study could provide relevant concepts to policymakers when formulating policy decisions related to DAPT.
Methods
Study Design and Participants
A cross-sectional survey was conducted to evaluate the awareness, perceptions, barriers, and perceived benefits of implementing a patient direct access policy in physical therapy centers across different regions in Saudi Arabia. The study was conducted in the period between January and April 2024. The study participants include licensed physiotherapists registered with the Saudi Commission for Health Specialties (SCFHS) working in various healthcare settings, including governmental, semi-governmental, and private institutions. Approached through convenience sampling. Inclusion criteria included male and female physiotherapists of all ages, qualifications, and years of experience, with a minimum of one year of clinical practice experience, and licensed with SCFHS. This criterion was established to ensure that participants had sufficient exposure to the field and could provide informed opinions and valuable insights regarding the research topic. Participants with less than one year of practice and those not obtained the SCHFS license were excluded from the study.
Study Variables
Independent variables included demographics such as age, gender, highest physical therapy qualification, primary work setting, job title, years of practice, and area of practice. Other study variables included physiotherapists’ awareness of direct access, perception of barriers and benefits to direct access implementation, and perceived benefits of various resources upon direct access implementation.
Sample Size and Data Collection
A sample size of 322 was estimated, with 95% confidence levels, margin error of 5%, and response proportion of 70% using Cochran’s formula, N=Z2 *p*q/d2. Around 400 physiotherapists were invited to participate in the study by sharing the link, according to their availability and willingness to obtain a diverse sample of professionals from different work settings and demographic characteristics. Two reminder e-mails were sent every week to increase the participation rate. With a response rate of 42.5%, a total of 137 respondents participated in the study. The questionnaire was produced in Google Docs, and the data was self-administered by the participants.
Research Instrument
The questionnaire was adapted from a survey developed by Bury and Stokes, which was utilized to evaluate the perspectives of WCPT members concerning patients’ direct access to physiotherapy clinics.14 The Bury and Stokes questionnaire is recognized globally and is the most widely used tool for assessing opinions on DAPT. Given the absence of a universal gold standard tool for assessing DAPT, the Bury and Stokes instrument was adapted due to its reputation as the most frequently referenced tool for this purpose.
A pilot study was conducted with five participants, selected from within and outside the institution, with a strong emphasis on years of experience and types of practice. The revised questionnaire underwent slight restructuring to address clarity issues identified during a pilot study. The data from this study were not included in the main research. Modifications in the sociodemographic section include making “age” an open-ended question, modifying work setting options to include government, semi-government, and private, and adding senior and junior levels for the title. Work environment consisted of outpatient setup, inpatient set up and home care, and the “current area of practice” an open-ended option, “others” was added in addition to the existing options like general practice, neurologic, sports, musculoskeletal, pediatric and cardiopulmonary. Furthermore, in section II, question number four, “Do you agree that direct access simply means when patients are referred to a physical therapist by a physician?” was removed, and two questions from Section VI, which pertained to the perceived benefits of resources, were also excluded. The overall reliability coefficient of 0.854 and a Cronbach’s alpha of 0.7 indicated the instrument’s high reliability. The survey consisted of six sections with fixed response options rated on a 5-point Likert scale. Section I consisted of demographic characteristics, Section II included awareness of direct access (Yes, No, Not sure), Section III contained views/perception on direct access implementation (Strongly agree, Agree, Neutral, Disagree, Strongly disagree), Section IV included perceived obstacles and barriers to direct access implementation: a list of potential challenges and asked to identify which challenges they believed could hinder the implementation of direct access in Saudi Arabia (1–5 scale, where 1 indicates small/little impact and 5 indicates huge impact), Section V had perceived benefits of current evidence-based practices: outlines advantages of current evidence-based practices (Strongly agree, Agree, Neutral, Disagree, Strongly disagree), and the final Section contained perceived benefits of various resources for direct access: addressed the level of importance of the anticipated resources that would be helpful in DAPT. (1–5 scale, where 1 indicates small/little impact and 5 indicates huge impact).
The highest possible score for the Awareness section was 3, while all other sections, including the perception of barriers and perceived benefits, had a maximum score of 5. In the Awareness section, a response of “No” received a score of 1, and a response of “Not Sure” was assigned a score of 2.
Statistical Methods
Data analysis was performed using IBM SPSS Statistics for Windows, Version 26.0 (Armonk, NY: IBM Corp). Descriptive statistics, including frequencies, percentages, means, and standard deviations, were calculated to summarize participant demographics, awareness levels, views, perceived benefits, and barriers related to direct access. The Kolmogorov–Smirnov test indicated that the data did not conform to a normal distribution; therefore, non-parametric tests (Mann‒Whitney U-test and Kruskal‒Wallis test) were employed to explore associations and differences between study variables and independent variables. A p-value <0.05 was considered significant.
The instrument used in this study has been widely utilized in research evaluating physiotherapists’ views on direct access and has proven to be valid and reliable in measuring awareness, views, obstacles, and perceived benefits associated with direct access to physical therapy.
Ethical Considerations
The study received ethical approval from King Saud University’s Institutional Review Board with approval reference number KSU-HE-24-109. Informed consent was obtained from all participants before the data were collected. The participants were assured of confidentiality, anonymity, and voluntary participation throughout the study. Ethical guidelines were strictly adhered to during all stages of the research process to ensure that the rights and well-being of the participants were upheld.
Results
The research comprised 137 participants, 46 (33.6%) males and 91 (66.4%) females. Most participants (86, 62.8%) were in the 20–30 years age range, 105 (76.6%) held a bachelor’s degree, and 83 (60.6%) were employed in the private sector. Among the total sample, 119 physiotherapists (86.9%) operated within an outpatient environment. Regarding their areas of practice, 62 participants (45.3%) engaged in general practice, 73 (53.3%) focused on sports or musculoskeletal medicine, and 38 (27.7%) specialized in neurology. Further demographic details are presented in Table 1.
Table 1.
Distribution of the Demographic Characteristics of the Study Participants (n=137)
| Variables | Frequency (%) | |
|---|---|---|
| Gender | Male | 46 (33.6) |
| Female | 91 (66.4) | |
| Age (years) | 20-30 | 86 (62.8) |
| 31-40 | 41 (29.9) | |
| 41-50 | 8 (5.8) | |
| 50 and more | 2 (1.5) | |
| Qualification | Diploma | 1 (0.7) |
| Bachelor | 105 (76.6) | |
| Master | 20 (14.6) | |
| Doctor in Physical therapy | 7 (5.1) | |
| PhD | 4 (2.9) | |
| Work setting | Government | 44 (32.1) |
| Semi-Government | 10 (7.3) | |
| Private | 83 (60.6) | |
| Work level | Junior | 78 (56.9) |
| Senior | 59 (43.1) | |
| Years of experience | 1-5 | 84 (61.3) |
| 6-10 | 28 (20.4) | |
| 11-15 | 12 (8.8) | |
| 16-20 | 8 (5.8) | |
| 21-25 | 2 (1.5) | |
| > 25 years | 3 (2.2) | |
| Work environment | Outpatient setup | 119 (86.9) |
| Inpatient setup | 53 (38.7) | |
| Patients home/Home care | 15 (11) | |
| Area of practice | General practice | 62 (45.3) |
| Neurology | 38 (27.7) | |
| Sports/Musculoskeletal Medicine | 73 (53.3) | |
| Pediatric Medicine | 31 (22.6) | |
| Cardiopulmonary rehabilitation | 17 (12.4) | |
| Other | 9 (6.6) | |
The level of awareness of direct access to physical therapy policy implementation is illustrated in Table 2. The overall mean score was 2.46/3. The theoretical knowledge, current practices, concepts, and effectiveness of direct access to physical therapy showed higher mean scores. However, regularized reading literature on direct access was the lowest score obtained (1.81 ± 0.91).
Table 2.
Level of Awareness of the Study Participants About the Policy Implementation of Direct Access to Physiotherapy Practice
| Item | No | Not Sure | Yes | Score (Mean ± SD) |
|---|---|---|---|---|
| Do you have theoretical knowledge of direct access to physical therapy? | 12 (8.8) | 35 (25.5) | 90 (65.7) | 2.57 ± 0.65 |
| Are you aware of current practices about direct access to physical therapy? | 22 (16.1) | 26 (19) | 89 (65) | 2.49 ± 0.76 |
| Do you understand the concept of direct access in physical therapy? | 12 (8.8) | 25 (18.2) | 100 (73) | 2.64 ± 0.64 |
| Do you agree that direct access will help in eliminating delays in the provision of effective care | 7 (5.1) | 15 (10.9) | 115 (83.9) | 2.79 ± 0.52 |
| Have you recently read any journals, articles, reports, or publications on direct access/self-referral? | 72 (52.6) | 19 (13.9) | 46 (33.6) | 1.81 ± 0.91 |
Notes: Maximum mean score =3. Data are reported as frequencies and percentages in parentheses except where otherwise specified.
Table 3 illustrates the association between awareness and demographic variables. Seniority at the work level was the only demographic variable that was significantly associated with a greater median awareness score (2.4:2.6; p=0.004).
Table 3.
Association Between Level of Awareness and Independent Variables
| Parameter | Awareness of Direct Access | U/H Statistic | p value | |
|---|---|---|---|---|
| Gender* | Male | 2.6 (0.8) | U=1782 | 0.157 |
| Female | 2.6 (0.6) | |||
| Age in years** | 20-30 | 2.6 (0.6) | H = 3.97 | 0.265 |
| 31-40 | 2.6 (0.8) | |||
| 41-50 | 2.5 (1.2) | |||
| 50 and more | 3 (0) | |||
| Qualification** | Diploma | 3 (0) | H=6.34 | 0.176 |
| Bachelor | 2.6 (0.6) | |||
| Master | 2.6 (0.7) | |||
| DPT | 2.8 (0.4) | |||
| PHD | 2.4 (1) | |||
| Work setting** | Governmental | 2.5 (0.9) | H=2.01 | 0.367 |
| Semi-Government | 2.7 (0.8) | |||
| Private setting | 2.6 (0.6) | |||
| Work level* | Junior | 2.4 (0.6) | U=1639 | 0.004 |
| Senior | 2.6 (0.6) | |||
| Years of experience** | 1-5 | 2.6 (0.6) | H=3.51 | 0.622 |
| 6-10 | 2.6 (0.5) | |||
| 11-15 | 2.6 (1.1) | |||
| 16-20 | 3 (0.6) | |||
| 21-25 | 2.4 (1.2) | |||
| > 25 years | 2.4 (1.2) | |||
Notes: Scores are presented as Medians (interquartile range). *Mann‒Whitney U-test. **The Kruskal‒Wallis test. P<0.05 considered significant.
Furthermore, the participants’ views on supporting the implementation of the policy were assessed using a scale scoring from strongly disagree to strongly agree, as illustrated in Table 4. Overall, a higher mean score of 3.92 ± 0.68 was obtained. However, their perceptions of physicians’ acceptance of the direct access model were slightly lower (3.53 ± 1).
Table 4.
Views and Perceptions of the Physiotherapists About Direct Access to Physical Therapy Care
| Item | Strongly Disagree | Disagree | Neutral | Agree | Strongly Agree | Mean ± SD |
|---|---|---|---|---|---|---|
| Do you agree to support this type of model, if it were to be implemented in Saudi Arabia? | 0 | 1 (0.7) | 26 (19) | 50 (36.5) | 60 (43.8) | 4.23 ± 0.78 |
| Do you agree to practice this type of model, if it were to be implemented in Saudi Arabia? | 0 | 1 (0.7) | 31 (22.6) | 53 (38.7) | 52 (38) | 4.14 ± 0.79 |
| Do you agree that policymakers are in favor of direct access/self-referral? | 0 | 15 (10.9) | 45 (32.8) | 43 (31.4) | 34 (24.8) | 3.7 ± 0.97 |
| Do you agree that the patients/clients/public are in favor of direct access/self-referral? | 1 (0.7) | 3 (2.2) | 38 (27.7) | 50 (36.5) | 45 (32.8) | 3.99 ± 0.87 |
| Do you agree that doctors/physicians are in favor of direct access/self-referral for physical therapy? | 3 (2.2) | 18 (13.1) | 47 (34.3) | 41 (29.9) | 28 (20.4) | 3.53 ± 1.03 |
Notes: Maximum mean score = 5. Data are reported as frequencies and percentages in parentheses unless otherwise specified.
Table 5 provides insights into the obstacles and barriers perceived by physiotherapists regarding the implementation of direct access in Saudi Arabia. The overall mean score was 3.14 ± 0.69. The most significant perceived barriers to DAPT were physicians’ perspectives (3.32 ± 1.1), laws and regulations to direct access (3.32 ± 1.2), lack of professional autonomy (3.2 ± 1.2), and existing insurance policies (3.2 ± 1.1).
Table 5.
Perceived Barriers to Direct Access Implementation as Seen by Physiotherapists
| Item | Strongly Disagree | Disagree | Neutral | Agree | Strongly Agree | Mean ± SD |
|---|---|---|---|---|---|---|
| Medical views (Doctors/Physician perspectives) | 11 (8) | 11 (8) | 64 (46.7) | 25 (18.2) | 26 (19) | 3.3 ± 1.1 |
| Lack of evidence-based practices | 12 (8.8) | 21 (15.3) | 64 (46.7) | 25 (18.2) | 15 (10.9) | 3.0 ± 1.1 |
| Prolonged Waiting lists/service demand | 13 (9.5) | 18 (13.1) | 51 (37.2) | 30 (21.9) | 25 (18.2) | 3.2 ± 1.1 |
| Scope of Practice of Physical Therapy | 16 (11.7) | 22 (16.1) | 59 (43.1) | 26 (19) | 14 (10.2) | 3 ± 1.11 |
| Lack of professional autonomy of Physical Therapy | 15 (10.9) | 17 (12.4) | 51 (37.2) | 33 (24.1) | 21 (15.3) | 3.2 ± 1.2 |
| Payment/reimbursement model (Insurance scheme) | 14 (10.2) | 13 (9.5) | 58 (42.3) | 35 (25.5) | 17 (12.4) | 3.2 ± 1.1 |
| Laws and regulations | 12 (8.8) | 19 (13.9) | 45 (32.8) | 35 (25.5) | 26 (19) | 3.3 ± 1.2 |
| Professional skills/competencies of Physical Therapists | 14 (10.2) | 21 (15.3) | 65 (47.4) | 24 (17.5) | 13 (9.5) | 3.0 ± 1.1 |
| Views of service users, ie, patients believe and trust | 16 (11.7) | 21 (15.3) | 52 (38) | 36 (26.3) | 12 (8.8) | 3.0 ± 1.1 |
| Self-perception/Image of Physical therapists | 19 (13.9) | 25 (18.2) | 51 (37.2) | 30 (21.9) | 12 (8.8) | 2.9 ± 1.1 |
Notes: Maximum mean score = 5; Data are reported as frequencies and percentages in parentheses unless otherwise specified.
Figures 1 and 2 illustrate the perceived and anticipated benefits of implementing direct access in physical therapy. The average agreement score was 4.24 ± 0.61 for the perception of benefits, while the perceived resource benefits obtained a score of 3.55 ± 0.88. Perceived benefits to direct access include improved professional status for physiotherapists, efficient access to outpatient services, and preventing aggravation of acute conditions to chronic.
Figure 1.
Mean scores of the perceived benefits of direct access implementation as seen by physiotherapists (Y axis = scores).
Figure 2.
Mean scores of the perceived resource- benefits of direct access implementation as seen by physiotherapists (Y axis = scores).
Table 6 illustrates the association between demographic variables and the perceived importance of anticipated resources to DAPT implementation. Older practitioners (p=0.011), and experienced physiotherapists (p=0.003) were found to have more positive expectations of the benefits of direct access.
Table 6.
Perceived Importance of Anticipated Resources to DAPT Implementation According to Demographics
| Parameter | Perceived Benefits of Direct Access | U/H Statistic | P value | |
|---|---|---|---|---|
| Gender* | Male | 3.63 (1.13) | U=1999 | 0.695 |
| Female | 3.63 (1.25) | |||
| Age, years** | 20-30 | 3.38 (0.88) | H=11.17 | 0.011 |
| 31-40 | 4 (1.13) | |||
| 41-50 | 4.38 (1.06) | |||
| 50 and more | 2.75 (3) | |||
| Qualification** | Diploma | 4.25 (0) | H=6.95 | 0.140 |
| Bachelor | 3.5 (1.13) | |||
| Master | 3.94 (0.75) | |||
| Diploma | 3.88 (1.5) | |||
| Doctorate | 3.5 (1.44) | |||
| Work setting** | Government | 3.88 (1.25) | H=4.55 | 0.103 |
| Semi-Government | 3.75 (1.13) | |||
| Private | 3.5 (1.13) | U=1976 | ||
| Work level* | Junior | 3.63 (1) | 0.113 | |
| Senior | 3.75 (1.25) | |||
| Years of experience** | 1-5 | 3.38 (0.88) | H=18.06 | 0.003 |
| 6-10 | 4.06 (0.75) | |||
| 11-15 | 3.88 (1.31) | |||
| 16-20 | 3.38 (1.37) | |||
| 21-25 | 4 (1.75) | |||
| > 25 years | 4.5 (0.25) | |||
Notes: Scores are presented as Medians (interquartile range). *Mann‒Whitney U-test. **The Kruskal‒Wallis test. P<0.05 considered significant.
Discussion
The present study investigated physiotherapists’ awareness and perceptions concerning the implementation of patient direct access to physical therapy services in Saudi Arabia. Although most physiotherapists exhibited a strong theoretical understanding of the DAPT concept, the research highlighted significant issues that must be resolved to ensure effective implementation.
Awareness and Perceptions
Most of the physiotherapists demonstrated an above-average level of awareness and understanding of the current practices related to patients’ direct access to the physical therapy model. Conversely, only 33% of these professionals indicated recent engagement with literature on direct access, highlighting a gap between knowledge and practical applications. This finding is consistent with previous studies15,16 and emphasizes the need for targeted educational initiatives and professional development programs to enhance practical implementation skills, particularly in diagnostic decision-making.17 Furthermore, senior practitioners demonstrated a higher awareness compared to their junior counterparts, suggesting that extensive experience significantly enhances the understanding of the complexities inherent in the healthcare system. Experienced physical therapists support direct access for several compelling reasons, the most important being patient-centered care with timely and expedited intervention. They are often strong advocates for patient education. Direct access allows them to guide patients through their rehabilitation process, enhancing understanding and compliance, which can lead to better treatment outcomes.
Barriers and Facilitators
Physiotherapists perceived strong self-support for DAPT implementation but anticipated limited support from physicians and policymakers. This finding is consistent with regional studies from Saudi Arabia but contradicts the Western literature.18,19 According to Al-Eisa et al, 58% of physicians had a negative perception of DAPT and were not in favor of approving the model.19 Conservative ideas may be influenced by environmental, cultural, and legislative factors, but qualitative research is needed to determine the reasons for negative perceptions and develop effective solutions. Exploring actual physicians’ perceptions and addressing their concerns regarding support, collaboration, and communication is crucial for successful DAPT implementation.20
Significant barriers perceived by physiotherapists included medical views, lack of evidence-based practices, payment/reimbursement models, and concerns about legislative laws. Overcoming these barriers requires a comprehensive approach, including policy adjustments, educational programs, and fostering collaboration among healthcare professionals.21,22 The role of insurance companies in policy implementation and sustainability is also crucial, as demonstrated by the successful DAPT implementation in the Netherlands following policy changes in insurance reimbursement.
The findings indicate that physiotherapists acknowledge substantial and positive advantages linked to the adoption of a direct access policy. The perceived benefits of DAPT included increased efficiency in accessing outpatient physical therapy services, improved patient satisfaction, enhanced professional status, and savings within the healthcare system. These findings align well with studies that evaluated the impact of DAPT.9 Helpful resources, such as leadership support, evidence-based literature, continuing professional development, and mentorship guidance, were identified as perceived benefits of resources, demonstrating an optimistic outlook on the transformative impact of DAPT on physiotherapy practices.
The worldwide relevance and importance of DAPT in improving healthcare services become apparent when our results are juxtaposed with existing literature. Research studies conducted in the United Kingdom, Croatia, Jordan, and the United Arab Emirates have revealed a positive attitude towards DAPT implementation and identified barriers like lack of training and resources, physician/medical views, and organizational laws and regulations similar to our study.19,23–25 These comparative findings highlight the common challenges and opportunities related to DAPT, offering essential insights for policy and practice considerations both within Saudi Arabia and in a broader context.
Implications for Practice
DAPT was initially developed as a proactive model to effectively address and manage pain in patients suffering from musculoskeletal disorders by direct access to physiotherapists. This model was safe and cost-effective since it reduced waiting times, prevented chronic complications, and reduced physicians’ workload.26 A systematic review of the DAPT model by Gallotti et al demonstrated DAPT to be a better work model than the usual physician referral pathway with no adverse events, improved costs, reduced return visits, and increased patient satisfaction, favoring DAPT implementation as a promising option to improve healthcare service.9 The model has been supported and adopted extensively in many European countries due to its positive clinical implications for clinical practice.27 Maselli et al summarized the model effectiveness, demonstrated its strengths, and contended for the adoption of the model in Italy.28 Moreover, physiotherapists can hold autonomous privileges due to unrestricted direct access, and well-trained physiotherapists can screen for red flags associated with other serious cervical and spinal pathologies.29,30
Policy Implications
The results of this study have important policy implications. The findings highlight the importance of promoting and advocating for direct access policies within healthcare institutions and among stakeholders, including policymakers, healthcare providers, and patients. The strong consensus to direct access policy implementation signifies the physiotherapists’ readiness, which could greatly improve patient care services and satisfaction.
Targeted educational initiatives, policy adjustments, collaborative efforts among healthcare professionals, and learning from global experiences are essential for the effective integration of DAPT in clinical practice. Collaborating with insurance providers to develop sustainable reimbursement models and engaging stakeholders to align their perceptions and expectations can help overcome potential barriers. Furthermore, investing in the education and training of physiotherapists to enhance their diagnostic skills and promote evidence-based practices will be vital in building trust and confidence in the DAPT model among healthcare professionals and patients alike.
Research Directions
The physiotherapists fear that physicians and policymakers are in lesser agreement toward DAPT implementation in Saudi Arabia. This necessitates the need to conduct an exploratory research to determine the actual perceptions of the physicians and the policymakers, including the reasons behind their views. Scientific evidence on the benefits of direct access over traditional referral systems in terms of patient outcomes must be explored in Saudi Arabia.
Limitations
This study has certain limitations. First, a convenient sampling method was applied, which may introduce bias into the study. Physiotherapists’ perceptions of physicians, patients, and policymakers reflect their views and may not necessarily be accurate. Since the data collection was self-administered, the data quality may be suboptimal due to missing data and a lack of responses from recall bias. The systematic self-report bias was unavoidable due to the nature of the study. The study obtained a lower response rate of around 42.5% despite sending two weekly reminder e-mails. As a result, the study might be underpowered to detect the differences, and this may affect the non-significant findings. This relatively small sample size may lead to non-response bias, low replication, and poor generalizability.
Conclusion
The findings suggest a potential support for DAPT implementation in Saudi Arabia while emphasizing the viewpoints on challenges and advantages associated with Direct Access to Physiotherapy in Saudi Arabia. The study pointed out the need for focused educational programs, interdisciplinary collaboration, and policy changes to effectively address these challenges and realize the expected benefits. By tackling these issues and fostering a supportive environment, the implementation of direct access could improve physiotherapy services, reduce referrals and waiting times, shorten treatment durations, and contribute to the overall advancement of healthcare in the Kingdom of Saudi Arabia. In conclusion, policymakers might consider endorsing DAPT in Saudi Arabia; however, addressing the barriers perceived by physiotherapists could reinforce the policy and lead to better results.
Funding Statement
This work was supported by the Ongoing Research Funding Program (ORF-2026-463), King Saud University, Riyadh, Saudi Arabia.
Abbreviations
DAPT, Direct Access to Physical Therapy; WCPT, World Confederation for Physical Therapy; SCHFS, Saudi Commission for Health Specialties.
Data Sharing Statement
Data is available with the corresponding author and can be shared upon reasonable request.
Ethics Approval
The study received ethical clearance from the Institutional Review Board of King Saud University with the approval reference number KSU-HE-24-109.
Consent to Participate
Informed consent was obtained from every participant before data collection from all the subjects involved in the study.
Author Contributions
All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.
Disclosure
The author(s) report(s) no conflicts of interest in this work.
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Associated Data
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Data Availability Statement
Data is available with the corresponding author and can be shared upon reasonable request.