Abstract
BACKGROUND:
The social position, perceived prestige and image of a profession are often of interest to members of that profession, and physiotherapy is no exception.
OBJECTIVE:
The aim of this study was to examine the perceived occupational prestige and image of physiotherapists and physiotherapy students in Turkey.
METHODS:
235 physiotherapy students and 465 physiotherapists were included in the study. A survey questioning occupational image, job satisfaction and prestige of the profession according to eight occupations was completed by the participants online.
RESULTS:
In terms of prestige, physiotherapy students ranked their profession fourth among eight undergraduate professions, while physiotherapists ranked their profession fifth. Compared to physiotherapists, physiotherapy students had more positive perceptions about their children becoming physiotherapists, the image of the profession in the eyes of the society, and job satisfaction (p < 0.05). Professional expectations of physiotherapists were higher than students. In addition, physiotherapists working for more than ten years had more positive perceptions about their children becoming physiotherapists, the public image of the profession, income level, and social standing, although perceived job satisfaction and need status were lower compared to physiotherapists with less than ten years of experience (p < 0.05).
CONCLUSION:
While physiotherapy students in Turkey perceived the prestige of the physiotherapist profession at a moderate level compared to other undergraduate professions, physiotherapists had a slightly lower perception of professional prestige compared to students. More comprehensive studies are needed on this subject.
Introduction
The concept of occupation is defined as the entirety of activities performed to produce useful products or services for people and earn money in return, attained through a certain education, based on systematic knowledge and skills, and governed by rules determined by the society. Occupation is the most important source of personal identity, and it is an area of activity that allows a person to be respected, to have a place in society, and to feel useful [1, 2]. Occupational prestige can be defined as the prestige and value attached to occupations by the individual, whether or not it has been transformed into an occupational preference. It is thus manifested by the sense of respect or appreciation individuals have for a particular occupational position [1–3]. Furthermore, the social standing of an occupation is called occupational prestige, and it is evaluated as the perception towards that occupation by different groups of people in society compared to other occupations. Occupational prestige is a useful indicator of the marketability and desirability of an occupation [4, 5]. High perceived prestige in an occupation increases the personal self-esteem and self-confidence of its members [6, 7]. Certain occupations, including medical, political and legal professions, are known to be associated with power, prestige, and material rewards [8]. Occupational image includes people’s opinions, thoughts and perceptions about an occupation. This is a very important factor in a person’s business life and career development as well as in choosing a profession [9, 10]. So much so that image is so effective and important in the modern world that the success of occupations depends on image as well as the quality, performance, technical knowledge, experience and abilities of the employees. Peregrin [11] defined occupational image as the sum of impressions (perceptions) towards an occupation.
The social position, perceived prestige and image of an occupation are often of interest to members of that occupation, and physiotherapists are no exception [12]. However, there are limited number of studies on this subject and the results are inconsistent [4, 12–14]. Several studies have reported that physiotherapy has a bad image and the professional status attached to it by medical practitioners and laypersons is negative [15–18]. Other studies evaluated the perceptions of physiotherapy students towards various occupations [5, 19]. Although one study defined the physiotherapist occupation as an intermediate occupation [5], there were also studies reporting that the perceived prestige of physiotherapy was high [5, 19]. Two studies were conducted with physiotherapists. In a study conducted in Nigeria [4], it was reported that physiotherapists perceived their occupational prestige as moderate, while another study in Saudi Arabia [13] reported poor perceived occupational prestige.
The university department that trained the first physiotherapists in Turkey was established in 1961 and was the only department training physiotherapists for 25 years. In 2008, this number increased to 13 and a total of 655 students graduated that year. By 2010, these numbers further increased to 23 and 1225. As of 2020, there are 90 physiotherapy departments in Turkey graduating 6082 students every year. Therefore, there has been a significant increase in the number undergraduate programs training physiotherapists and the number of graduates in the last 12 years [20]. Several studies reported that this increase negatively affected the employment time and employment status of newly graduated physiotherapists [20–23]. In addition, this dramatic increase in the numbers may negatively affect the perceptions of physiotherapists and physiotherapy students about the profession in Turkey. However, there are no studies in Turkey conducted on perceived prestige and image of physiotherapy and the effect of this increase on the profession perceptions cannot be discussed. In addition, there is no study comparing the perceptions of the profession between former graduates and recent graduates. For this reason, with the current study, it is desired to form the initial basis for the studies to be carried out on this subject and to raise awareness about what should be done in this regard if the professional prestige and image are found to be low as a result of the current study. The first question of the current study is what is the level of perception of physiotherapists and physiotherapy students in Turkey towards the professional prestige and image of physiotherapy. The second question is whether the professional image and prestige perceptions of former graduates, new graduates and students are different. Third question is to investigate the perceived occupational perception due to the increasing number of physiotherapy departments in Turkey and its affects the perceptions of physiotherapists and physiotherapy students about the profession. In the light of the above information, the aim of this study was to examine the perceptions of physiotherapists and physiotherapy students in Turkey towards occupational prestige and image of physiotherapy.
Materials and methods
Participants
This comparative analysis study was conducted as a cross-sectional study between March and July 2022. Ethical approval for the study was obtained from Acibadem University and Acibadem Medical Research Ethics Committee (Ethics committee number = 2022-01/11) and clinical trial approval (U.S. National Library of Medicine clinical trial registration no: NCT05302869) was received. Sample size for students was calculated based on a population of 6082 students, 85% confidence interval, 4% margin of error, and 0.5% standard deviation. The sample size was determined as 246 (z score = 1.28). For physiotherapists, sample size was calculated based on a population of 35,000 physiotherapists, 90% confidence interval, 4% margin of error, and 0.5% standard deviation. The sample size was determined as 420 (z score = 1.65). As a result, creating online questionnaire [12] with Google Form was sent to 600 physiotherapy students and 1500 physiotherapists via e-mail (member of Google groups where physiotherapists and students in Turkey are registered) and social media (author’s social media) by convenience. Of the 250 physiotherapy students and 475 physiotherapists who accepted the consent form, 15 physiotherapy students and 5 physiotherapists were excluded from the study because they did not answer all the questions of the form. We think that the people who did not answer the questions are due to the use of online surveys in too many studies during the COVID-19 period. Those who were not actively working as physiotherapists were excluded from the study (n = 5). The study was completed with the participation of 235 physiotherapy students and 465 physiotherapists, whose written consent was obtained within the framework of the Declaration of Helsinki and who completed the questionnaire. Since the number of graduates has increased in recent years and the perceptions of physiotherapists may differ according to their graduation year, physiotherapists were further divided into three groups: Group PT 1 = graduate with 0–5 years of experience (n = 244) Group PT 2 = graduate with 5–10 years of experience (n = 121) Group PT 3 = graduate with more than 10 years of experience (n = 104)
Instruments
An online questionnaire was prepared in accordance with the relevant literature [12]. Following the demographic characteristics of participants (age, gender, parental education status), various questions were asked to measure their perceptions and images about physiotherapy professions. These questions were: Would you like your daughter/son to be a physiotherapist? What do you think is the public image of the physiotherapy profession? What is your current satisfaction level as a physiotherapist/ physiotherapy student? What is your current expectation as a physiotherapist/physiotherapy student?
The questionnaire prepared by Turner [12] to determine occupational prestige was modified to make cultural adaptations during a two-step focus group discussion. In the first step, four physiotherapists and four physiotherapy students participated in the focus group discussion. The lead author moderated the discussion, another author took notes, and the third and fourth authors acted as observers in the focus group discussion. Focus group participants excluded chiropractic and osteopathic professions from the questionnaire due to the absence of these occupations in Turkey. Participants also stated that mechanics, bartenders, police officers and cleaners did not require long-term education after primary and secondary education, thus it would not be correct to make a comparison between these and the physiotherapist profession. Accordingly, occupations requiring undergraduate education were kept in the questionnaire. Another reason for removing these occupations was to keep the questionnaire short, as a large number of online survey studies have been conducted in general during the COVID-19 pandemic. In addition, the final occupations were selected from the most well-known professions in the society. Since lawyers, judges and prosecutors all practice law, these occupations were grouped under the category ‘law’. Furthermore, considering that the 6-point Likert scale might be confusing, it was replaced with the Visual Analog Scale (0–10) [24]. The reason for this was the easier adaptation of physiotherapists and physiotherapy students to this Likert system. Zero was defined as “none” and ten was defined as “the highest level I can think of”. In the second step, the modified questionnaire was used 10 physiotherapists and 10 physiotherapy students in a focus group discussions. Participants were asked whether they had difficulties in understanding or filling out the questionnaire. The participants stated that they did not experience any difficulties, and the questionnaire was finalized in this form. In addition, education level, income level, social standing, responsibility, level of usefulness, female gender ratio, and occupational needs were also questioned.
Statistical analysis
Statistical analysis was performed using SPSS software (version 22.0). Data were expressed as “mean±standard deviation” or number of subjects (n) and percentage (%). “Shapiro Wilk test” was used to check whether the data conformed with normal distribution. Categorical variables were evaluated with the “Chi-square test”. For numerical variables, the differences between two groups were evaluated with the “Independent Sample T test” and the differences between three or more groups were evaluated with the “One-Way ANOVA” and post-hoc Tukey test. “Pearson Correlation Analysis” was used to evaluate the relationship between parameters. Correlation coefficient (r) of 0.7 and above was classified as strong correlation, r between 0.3–0.7 was classified as moderate correlation, and r below 0.3 was classified as weak correlation [25]. P < 0.05 was accepted as statistically significant for all analyses.
Results
The perceived occupational image and satisfaction results of physiotherapy students and physiotherapists are shown in Table 1. While more physiotherapy students wanted their children to be physiotherapists compared to physiotherapists (p < 0.001, all, Table 1), this rate was higher in Group PT3 compared to other physiotherapist groups (p = 0.006–0.024, Table 1). While students had a better perceived public image compared to physiotherapists (p < 0.001), perceived public image was better in Group PT3 compared to Group PT1 (p = 0.002). Physiotherapy students were more satisfied with studying physiotherapy compared to physiotherapists (p < 0.001, Table 1), while Group PT3 was less satisfied compared to other physiotherapist groups (p < 0.001, Table 1). While occupational expectations of the physiotherapy students were at the level of “somewhat satisfied” compared to the physiotherapists, the expectations of the physiotherapists were higher (p < 0.001, Table 1).
Perceived image and satisfaction results of physiotherapy students and physiotherapists
Perceived image and satisfaction results of physiotherapy students and physiotherapists
n. number of people; aIndependent Sample T test; bOne Way ANOVA and Tukey post hoc test; others chi-square test; Values in bold show statistical significance.
Occupational prestige of physiotherapy perceived by physiotherapy students and physiotherapists compared to other professions are shown in Table 2. In terms of education, physiotherapy students ranked physiotherapy second after doctors, while physiotherapists ranked themselves fifth among eight professions. Physiotherapy students ranked the education level of physiotherapy as higher than the physiotherapists (p < 0.001, Table 2). In terms of income level, both students and physiotherapists ranked their occupation last among all occupations, but perceived income status was significantly worse for physiotherapists compared to students (p < 0.001, Table 2). Perceived income level was better in Group PT3 compared to other physiotherapist groups (p < 0.001, Table 2). In terms of social standing, students ranked their profession seventh among eight professions, while physiotherapists ranked their profession last (p < 0.001, Table 2). Perceived social standing was higher in Group PT3 compared to other physiotherapist groups (p < 0.001, Table 2). In terms of responsibility and level of usefulness, both students and physiotherapists ranked their profession second after doctors, but perceived level of responsibility was higher among students (p < 0.001, all, Table 2). In terms of female ratio, both students and physiotherapists ranked their profession fourth. In terms of needs status, students ranked their profession second after doctors, while physiotherapists ranked their profession fourth. Perceived needs status was higher among students (p < 0.001, Table 2). When all dimensions except female ratio were considered, physiotherapy students ranked their profession fourth among eight professions, while physiotherapists ranked their profession fifth.
Occupational prestige perceived by physiotherapy students and physiotherapists
aIndependent Sample T test; bOne Way ANOVA and Tukey post hoc test; Values in bold show statistical significance.
The aim of the present study was to examine perceived occupational image and prestige in physiotherapists and physiotherapy students in Turkey. While perceived prestige of students was moderate compared to other professions (fourth among eight professions), it was lower among physiotherapists (fifth among eight professions). In addition, physiotherapy students were more positive compared to physiotherapists about wanting their children to be physiotherapists, the public image of the profession, and job satisfaction. Physiotherapists had higher expectations from the profession than students. Furthermore, physiotherapists with more than ten years of work experience had lower perceived job satisfaction and needs status compared to physiotherapists with less than ten years of work experience; however, they were more positive about wanting their children to be physiotherapists, public image of the profession, income level, and social standing.
There are limited studies examining the perceptions of physiotherapists towards their profession. In recent review, it was reported that the physiotherapy profession is generally perceived positively by current and future physiotherapists, and it was also added that public awareness about this profession is low [14, 26]. Many studies in the literature focused mostly on recognition of the profession and the services it provides. These studies evaluated patients and non-patients [27, 28], high school students [29], medical practitioners [30, 31], physiotherapy and health science students [32–34], and physiotherapists [35]. The rationale behind these studies was to investigate the perceived professional position of physiotherapy relative to others, including other medical professions. Literature results often show physiotherapy as lacking a clear identity. Additionally, empirical evidence tends to support the views of individual authors who have expressed concerns about the perceived position of the occupation [16, 37]. Although this situation has changed in recent years, these negative perceptions may still affect current and future physiotherapists to have a negative occupational image and prestige. The present study is the first study conducted in Turkey to determine how current and future physiotherapists are affected by the steady increase in the number of physiotherapy graduates over the past 12 years. To determine occupational image perceived by the participants, the question “Would you like your child to be a physiotherapist?” and other questions about the public image of the profession were asked. While approximately 59.60% and 61.30% of physiotherapy students had positive views about their daughters and sons becoming physiotherapists in the future, this rate was significantly lower among physiotherapists (27.50% for daughters and 26.90% for sons). This results is consistent with studies reporting that students and fresh graduates have higher perceptions of their profession, while those with more work experience have lower perceptions. Interestingly, physiotherapists with more than 10 years of experience had positive views about their daughters and sons becoming physiotherapists in the future compared to physiotherapists with less than 10 years of work experience (33–36% vs. 17.40–29.90%). In terms of public image, income level and social standing, physiotherapists with more than 10 years of experience had more positive perceptions compared to physiotherapists with less than 10 years of experience. This may be due to the exponential increase in the number of physiotherapists in Turkey, creating a more difficult environment for new graduates to be employed [21, 38]. In addition, the fact that students and physiotherapists think that the public image of physiotherapists is moderate also supports their concerns about the perceived position of the profession in accordance with the literature reports mentioned above.
Occupational prestige is a useful indicator of the marketability and desirability of an occupation [4, 12]. In the current study, the dimension of education was initially asked to students and physiotherapists to assess occupational prestige. In previous studies on this subject [5], physiotherapy students in the UK placed their profession in fourth place, and students in Australia placed their profession in third place after doctors and judges [12]. Physiotherapy students in the USA [19] ranked their profession fourth in terms of education level after doctors, lawyers and judges. In two other studies, students ranked physiotherapy first in Albania [14] and sixth in Saudi Arabia [13]. In other studies, physiotherapists in Nigeria [4] ranked their profession second after doctors, while it was ranked seven in Saudi Arabia [13]. Interestingly, in the present study, students ranked the educational level of the profession second after doctors, while physiotherapists ranked it fifth. This may be due to the increasing number of courses and trainings related to physiotherapy in Turkey in recent years, and the increasing level of education in the new generation as these systems begin to be implemented in universities. In addition, the students may also have higher levels of perceived education level compared to physiotherapists in a manner similar to the study conducted in Saudi Arabia [13].
In terms of income, physiotherapy students ranked their profession seventh in the UK [5] last (sixth) in USA [19], sixth in Australia [12], fourth in Albania [14], and last (ninth) in Saudi Arabia [13], while physiotherapists ranked their profession seventh in Nigeria [4] and last (ninth) in Saudi Arabia [13]. In the present study, both students and physiotherapists ranked the profession last among all occupations (eight), consistent with the literature, while physiotherapists had a significantly worse image of their profession compared to students, similar to the results in Saudi Arabia [13]. In terms of social standing, physiotherapy students ranked their profession fifth in the UK [5], fourth in USA [19] after doctors, judges and police officers [12], third in Australia after judges and doctors, second in Albania [14], and ninth in Saudi Arabia [13], whereas physiotherapists ranked their profession sixth in Nigeria [4] and ninth (last) in Saudi Arabia [13]. In Turkey, physiotherapy students ranked their profession sixth, while physiotherapists ranked it seventh. Social standing or societal position defines an individual’s position within a particular society and culture and determines the individual’s place in a social environment or organization. It is also an important measure of prestige [5, 39]. Perception of low social standing by physiotherapists and physiotherapy students in Turkey may be negatively impacting self-perception and self-confidence [6, 7] and may reduce the future preferability of the profession [6, 39]. As a matter of fact, the scores of physiotherapy departments required at the university entry examination are decreasing in Turkey, which further supports this deduction. In terms of responsibility, physiotherapy students ranked their profession third in the UK [5], sixth (last place) in the USA [19], third in Australia after judges and doctors [12], second in Albania after doctors [14] fifth in Saudi Arabia after doctors, pharmacists, nurses and soldiers [13], whereas physiotherapists ranked their profession fifth in Nigeria [4] and in Saudi Arabia [13]. In the present study, both students and physiotherapists ranked their profession second after doctors. In other words, physiotherapy students and physiotherapists in Turkey perceived more sense of responsibility in terms of education, income level and the level of social standing. Since individuals with a higher sense of responsibility can make their own decisions, use resources effectively and correctly, act independently, are self-confident and do not violate the rights of others, this result is more important in terms of the prestige of physiotherapy profession in Turkey compared to other dimensions. In terms of level of usefulness, physiotherapy students ranked their profession fourth in the UK [5], second in the USA [19], third in Australia [12], second in Albania [14], and third in Saudi Arabia [13], whereas physiotherapists ranked their profession third in [4] and in Saudi Arabia [13]. In the present study, consistent with the literature, both students and physiotherapists ranked their profession second in this dimension. In conclusion, physiotherapy students had high perceived occupational prestige in Albania [14] (second out of 11 professions), Australia [12] (third out of 12 professions), and USA [19] (fourth out of 13 occupations), whereas perceived occupational prestige was moderate in the UK [5] (fifth out of 12 professions) as well as in Turkey (fourth out of eight professions). In contrast, perceived occupational prestige was low among students in Saudi Arabia [13] (sixth out of nine professions). Studies conducted with physiotherapists are limited. While occupational prestige of physiotherapists is above average in Nigeria [4] (ranked fourth out of 12 occupations), it is below average in Saudi Arabia [13] (ranked seventh out of nine occupations). In the present study, physiotherapists ranked their profession fifth among eight professions, revealing a moderate level of perception. Although cultural differences may have an effect on different perceptions in different countries, we think that the main factor is the ratio of the number of physiotherapists to the general population, the differences in salary, working environment and conditions, and the problems in occupational laws, including occupational autonomy. As a matter of fact, in a study conducted by the lead author, it was found that “the employer’s expectations from the employees differed according education, physiotherapists had poor working conditions and lack of autonomy, number of patients seen by physiotherapists was high in order to fill quotas, especially in hospitals in contract with the social security institution, sessions were very short, and salaries decreased over the years", which were identified as factors reducing job satisfaction. These findings are consistent with the results of the present study. For this reason, we think that the health policies regarding the physiotherapy profession should be amended in Turkey and new regulations should be introduced. In addition, the increasing number of graduates, difficulty of finding a job, and the decrease in occupational prestige also lead to an increasing effect on hopelessness felt by physiotherapy students over the years [23, 40]. Consistent with this conclusion, the expectations of the students were lower compared to the physiotherapists in the present study. This finding highlights the importance of introducing these regulations as soon as possible.
We also examined perception of needs status and job satisfaction and expectation in the present study in order to determine whether we would see a difference in these dimensions due to the increase in the number of physiotherapy students and graduates in Turkey. In terms of needs, physiotherapy students ranked their profession second after doctors, while physiotherapists ranked their profession fourth. This shows that physiotherapy is still a desirable occupation, and, similar to the perception of responsibility, can be evaluated as a positive finding. At the same time, physiotherapy students were more satisfied with studying physiotherapy compared to graduate physiotherapists, while former graduates (over ten years) were less satisfied compared to recent graduates (under ten years). In a study conducted in Austria, it was shown that physiotherapists were generally very satisfied with their jobs [38]. In Germany, physiotherapists were shown to have a higher job satisfaction than other health professions such as nursing [41]. In contrast, the perception in Turkey is different from the literature and job satisfaction is lower, most likely due to the reasons explained above.
Job satisfaction is how an individual feels about his job. Since professional image includes people’s opinions, thoughts and perceptions about a profession, it can be predicted that it can affect job satisfaction [42]. Job satisfaction can also be affected by the stress at work and the musculoskeletal diseases experiences during work. It has been reported that physiotherapists experience a high job stress, and this situation decreases as their professional experience increases, while the rate of developing musculoskeletal diseases is as high as 90%. It has been reported that 50% of them experience musculoskeletal disorders, especially in the first five years [43]. Work-related musculoskeletal complaints show that physiotherapists are vulnerable to musculoskeletal diseases due to overload and inappropriate postures [44–46], which negatively affects their quality of life [47]. Perhaps this is one of the reasons for the differences observed in our study results between students and graduate physiotherapists. However, because our study did not investigate musculoskeletal disorders and quality of life processes, we cannot discuss this opinion. This is one of the limitations of our study. Another limitation is work environment does affect job satisfaction aswell, which was not included in our study. Further studies are needed to assess the perception of the occupation and relationship between work environment and quality of life in physiotherapists.
There are certain limitations of this study. The sample size represents only a portion of all physiotherapists and physiotherapy students in Turkey, and the results cannot be generalized to the entire population. Further studies are needed on this subject.
Conclusion
Based on the results of the present study, it can be concluded that physiotherapy students in Turkey had a moderate level of perceived occupational prestige, while physiotherapists had a slightly lower level of perceived occupational prestige. Physiotherapy students had more positive perceptions compared to physiotherapists in terms of wanting their children to be physiotherapists, public image of the profession, and job satisfaction. In addition, although physiotherapists with more than ten years of experience had lower job satisfaction and perceived needs status compared to physiotherapists with less than ten years of experience, they had more positive perceptions in terms of wanting their children to be physiotherapists, public image of the profession, income level, and social standing. To increase the perception of professional prestige of physiotherapists, more studies needed to discuss with the occupational associations on this subject. It is thought that it would be beneficial for the occupational associations to organize such educations, seminars and workshops for physiotherapists which musculoskeletal problems are common. More comprehensive studies are needed on this subject.
Ethics approval
This comparative analysis study was conducted as a cross-sectional study. Ethical approval for the study was obtained from the Acibadem University and Acibadem Medical Research Ethics Committee (Ethics committee number: 2022-01/11) and clinical trial approval (U.S. National Library of Medicine clinical trial registration no: NCT05302869) was received.
Informed consent
The study was carried out according to the Declaration of Helsinki. Written informed consent was obtained from all participants.
Conflict of interest
The authors declare no competing interests.
Footnotes
Acknowledgments
Not applicable.
Funding
None declared.