Physical activity and health-related quality of life among physiotherapists in Hebron/West Bank

Early on in Physiotherapists (PTs) career, many physiotherapists drop out of their jobs or at least drop out of clinical work [5][6]. Many factors contribute to the attrition of physiotherapists, including raising a family and further education [7]. In addition to the burnout phenomenon and their related with physical activity [8,9]. Moreover, several studies have shown disorders in PA have a major impact on the longevity of physiotherapists work as well as the effect on health-related quality of life [10].


Introduction
Physical activity (PA) is de ined as the consumption of energy in muscle contraction, which leads to movement of the body. PA is closely related to the musculoskeletal muscle itness that affects the health prevention strategies [1,2]. PA is an essential tool in preventing movement disorders and chronic disabilities [3,4].
Early on in Physiotherapists (PTs) career, many physiotherapists drop out of their jobs or at least drop out of clinical work [5] [6]. Many factors contribute to the attrition of physiotherapists, including raising a family and further education [7]. In addition to the burnout phenomenon and their related with physical activity [8,9]. Moreover, several studies have shown disorders in PA have a major impact on the longevity of physiotherapists work as well as the effect on health-related quality of life [10].
The disorders affect PTs with little experience compared to those with signi icant experience. The PT needs a lot of manual force to perform manual therapy, which further develops musculoskeletal problems [11]. Previous studies have shown that musculoskeletal disorders has a clear effect on the physiotherapist›s work during a range of clinical settings [12][13][14].
The PTs health is also affected by the private lifestyle they live in, which affects their job performance, and thus in turn affects health care services. Therefore, the demand for monitoring these services increases through quality control and quality management. Because the profession of PTs deals with physical activity directly, many studies have shown the health care workers play a key role in ighting physical inactivity [15]. physical inactivity affects the PTs on selfcon idence, social attitudes, mental health, and perceived stress [16]. Because PA is important in the professional life of a PT, it is important to know the PA and its role in in luencing health-related quality of life. Therefore, the aim of the study was to establish the physical activity levels of physiotherapists in Hebron-West Bank and their physical activity health promotion practices.

Study design
This study was based on a cross section of PTs. It was conducted at different physiotherapy centers in Hebron, Palestine, after the ethical approval of those centers was obtained. The study sample was 150 PTs across 42 different physiotherapy centers.

Participants and setting
The study was based on PTs who worked for more than 6 hours daily. The study excluded any PTs who did not work at least 6 hours daily, or those with any disability or musculoskeletal disorder.

Measurements
The data was collected using the SERVQUAL questionnaire. The questionnaire includes information about the PTs, which includes gender, age, and educational quali ication. The study tool used was a health survey form represented in Short Form-36 (SF-36). The questionnaire measures several mental and physical health aspects, including general health, physical functioning, body pain, emotional problem, and selfknowledge for the body health.
The questionnaire was built on the Likert scale items, the service quality is measured by ive grades, starting with strongly disagree, disagree, neutral, agree, and strongly agree.

Data analysis
A SPSS 10.0.1174 software was used for data analysis. Tables were used to express descriptive analysis, While the bar chart was used to represent igures. Data and information analysis were based on the use of three tests: Descriptive statistics, Pearson correlation, and Mann-Whitney U test.

Results
The reliability of the data collection questionnaire was measured using Cronbach's Alpha test 76.4%. This value is good enough for the reliability to take the current results.
A total 150 of participants are collected in this study. The PT centers were divided into 42 centers. Demographic information was analyzed descriptively (number and percentage) and presented in table 1.
The results showed that 56% of the participants were males and 44% of them were female. It is also shown that the majority of the participants (46%) are between the ages of 25 and 30 years, and the minority are between the ages of 35 and 40 years. In the same table, we also can see that most of the participants (78%) have a bachelor's degree. However, the minority (4%) have Ph.D. Table 2 shows the general health of the participants. It was distributed into four groups; excellent; very good; good; and not bad. As shown in table 2, 60% of the participants have very good health in general. While the majority of participants (48%) reported that they were no different than the previous year. However, 12% of the participants reported that their health is currently better than it was in the previous year.

Physical functioning
Physical functioning was measured in this study and consisted of nine sections. Figure 1 shows these aspects and the main differentiation in each section.
As shown on igure 1, 36% of the participants agreed that there are limitations to doing vigorous activities, such as running, lifting heavy objects, or participating in strenuous sports. However, 8% of the participants disagreed.
Regarding moderate activities, 22% of the participants reported that their health currently limits their ability to do moderate activities, such as moving a table, pushing a vacuum cleaner. However, most participants -32% -reported that their physical activity was not reduced.  Regarding lifting and carrying groceries, 36% of the participants reported they could do these activities without dif iculty. The results also showed a luctuation between participants and their ability to walk up the stairs for several loors without any problem. In addition to that, the majority of participants (62%) do not have any problem going up one light of stairs.
In the same igure, we can see that most participants (34%) don't have problems when bending, kneeling, or stooping. But 12% do have problems with these actions. Regarding the ability to walk half a kilometer, the results showed that the majority of participants could walk this distance without problems, while 8% reported problems with the ability to walk such a distance. Moreover, most of the participants reported they can walk 100 meters without any dif iculties, and this result supports the previous result. Finally, the results show that the participants are able to take a shower and dress themselves unaided.

Physical health
To measure Physical health, the researcher made a yes or no question with ive sections; cut down the amount of time one spent on work; accomplished less than you would like; limitation in kind of work; dif iculty performing work; Complete an activity. Figure 2 shows the results of these questions.
The results shown are the participants reports of any dif iculties that physiotherapists may suffer during their normal daily activities as a result of their physical and mental health over the past month. Figure 2 shows that most of the participants agreed that they were facing dif iculties in their daily work.

The body pains
In this study, body pain was divided into four sections: physical and psychological health; the body pain; pain effects; and the effect of the pain on social functioning. Figure 3 demonstrates all of these differentiate.
As the Figure 3 shows, 34% of the participants reported little difference in health problems affecting their normal social activities. We can also see that the majority of participants reported they had no pain over the past 4 weeks. However, more than 45%, making the majority, reported pain, but at the same time, the participants reported that the pain did not affect their social activities.

Emotional problem
Emotional problems were measured by using 9 questions which examined: activity and vitality; nervous person; depression; quiet and safe; energy; frustration; exhausted; happy person; and tired. Figure 4 demonstrates the main results for this section.    As shown in igure 4, most of the participants felt vitalized, at the same time they did not feel angry most of the time. However, most of the participants reported feeling depressed at work during the past 4 weeks.
In addition, the majority of the participants reported feeling calm and safe at work. Moreover, most of them reported having energy. However, they reported that some of the time they felt frustration and fatigue. Despite that, most of them feel happy when working, while also feeling tired a little of the time.

Self-knowledge for the body health
The study also examined the self-knowledge of the participants of their body health. The results show that most of participants had a good level of knowledge of their own body health. Figure 5 shows the most of participants disagreed that the racetrack was easier for them than others, while most of them agreed that their health was equal to that of the others. Regarding predicting how much their health would worsen, most of the participants agreed that their health had improved, and this is supported by the result of the last question where most of the participants reported their health was excellent.

The correlation between of physical health on the physiotherapist's daily work
The relationship between age and activities in daily life was measured using Pearson correlation. The correlation in table 3 shows there are no signi icant differences between both age and ADL.

The correlation between age and general health
To con irm the previous result, the relationship between general health and different age groups was assessed using the Pearson correlations. Table 4 illustrates there are no signi icant differences between the age and general health of the participants, except in those aged over 40, where we see a signi icant difference in their general health. However, the small sample size does not indicate this result can apply as a general result for all participants.

The correlation between body pain and general health
The pain or discomfort considered the biggest contributing factor on the general health of the physiotherapists, despite the small portion of participants who reported this. However, the analysis shows there is a signi icant difference between them with Sig. (2-tailed) 0.006 which is less than 0.05. These results are shown in table 4.

The correlation between the general health and the gender of physiotherapists
Using the none parametric Mann Whitney test , table 5 shows there is statistically signi icant difference between males and females in relation to general health p < 0.05.

The correlation between physical and psychological health and the gender of physiotherapists
The correlation between gender and physical and psychological state was investigated using Mann-Whitnev U test. The result show there is no signi icant difference between physical and psychological state and gender with sig tailed equal to 0.457 which is more than 0.05. This result shown in

The correlation between physical and psychological and the age of physiotherapists
The physical and psychological health was measured using the average of three variables including physical pain, and psychological and social aspects. Using the Pearson correlation test there was a statistically signi icant positive correlation between these aspects and age. It seems that age negatively affects the psychological health p < 0.05. These results are shown in table 6. to their peers in the general population especially in resilience and psychological morbidity. In the same ield the study was focused on the correlation between gender and physical and psychological health. As shown in the below section males psychological and physical health is better than females. Even though this difference was not statistically signi icant (p > .05). In another study which was conducted by Campo, et al. [26] showed female therapists were more likely than male therapists to suffer pain through works due to their job. Also, the female therapists were more likely to be less active whilst working. Also, there are different previous studies which show that male physiotherapists were reportedly in considerably in better general health than female physiotherapists [27][28][29][30].
Our study also showed there were no differences between male and female physiotherapists with regards to their physical and psychological health. However, this result was different to that found by Muadi, et al . [31] conducted, and the results of that study found there was a signi icant correlation between physical demands, work setting, BMI and gender.
Another study conducted in the society of Japan showed the younger participants were more physically active than their older counterparts, due to the difference in the lifestyles between them. The current study demonstrates similar results in the PTs community [32].
The current study was based on a cross-sectional analysis. Therefore, the cause-and-effect determination was not suf iciently accurate. In addition, the level of the effect of physical activity on the physiotherapists was determined by the self-reported questionnaire of, thus the extent of the effect cannot be accurately estimated. There is a need for future studies to be conducted to assess the effect of physical activity on HRQOL for physiotherapists in clinical and non-clinical practices

Conclusion
Physical activity of a physiotherapist affects HRQOL, which in turn affects their job performance. Physical functioning and psychological improvement increase the physical activity. The current study achieved its aims and gave a future vision about the situation facing the physiotherapists in Palestine and their job performance. Community-related characteristics must be understood to enhance the physical activity of this group.

Discussion
Physical activity consists of four aspects: the physiological aspect, the psychological aspect, the social aspect, and the development aspect [17]. Physical activity directly affects Health-related quality of life (HRQOL). The HRQOL system is validated in several respects, which includes the four aspects previously mentioned [18]. Physical activity affects physiotherapists, which in turn affects their HRQOL system [19]. The study showed that Most participants feel vitality, depression, quit, have energy, and are happy in the most of the time. In addition, most of them believe their health is similar to that of the members of the surrounding community. The female group more affected than man physical and psychological with their age.
The current investigation indicates that most of PTs in the current sample were already in a good state of health physical activities and this result supported the hypothesis of the study. The physical activities included walking and vigorous activities such as running, lifting heavy objects, and strenuous sports. Our results show that there is not a clear difference between age and the physiotherapist's daily work have not a clear difference. This result is consistent with previous studies [20][21][22].
In the younger age group, general health levels reported were very good compared with that of older PTs. The signi icant difference was the older participants' general health as shown in this study. This result was considerably better health-related quality than previous study which was done in Australia [23,24]. In general, the general health of the participants in the same age group is considered very good.
The current study appears to show that the male participants have better health in general compared to the female participants. This signi icant difference was similar to Éva works [25], who shows that the female physiotherapist unlike to the males which experienced higher stress compared