The objective of the study is to understand the similarities and differences between pelvic health physiotherapists (PHPTs) clinical reasoning (CR) processes and decision-making in the United Kingdom (UK) and the Kingdom of Saudi Arabia (KSA) while assessing and treating patients with urinary incontinence (UI). Comparing between PHPTs reasoning and decision-making (DM) in two different countries with different individual and organisational cultures may contribute toward the understanding of the influence of cultures on physiotherapists’ decision making and clinical reasoning while managing patients with UI. There are limited studies that explore the influence of culture on physiotherapists’ DM and clinical reasoning in the UK and other countries. In a recent review of the literature to understand how physiotherapists consider patients’ culture in management decisions. The authors found that there is limited consideration of patients’ culture in physiotherapists' goal setting and management plans (Yoshikawa et al. 2020). Incontinence has a negative impact on patients' emotional, social, and quality of life. Patients with UI may avoid physical activities because they might be worried about leaking or odour after exercises. The culture of secrecy, sense of shame and self-blame for UI limit help-seeking for UI in women from ethnic minorities. Some Muslim women may be hesitant to undertake Uro-gynecological tests because there are customs that demand that women should expose certain body parts to their husbands only. It can be assumed that the lifestyles women have will affect how UI is experienced. It is therefore likely that women in different countries and cultures experience and perceive incontinence differently. It is also possible therefore that PHPT DM and CR may vary in different cultures. Moreover, most of the research on physiotherapy CR has been conducted in Western democratic countries. Relatively little is known about CR in other cultures or how culture may shape CR. It cannot be assumed that CR in Western countries will be equivalent to that used in other cultures. This premise is explored in this study by including participants from two different countries, i.e., the UK and KSA.

Using a qualitative design, PHPTs’ were interviewed with semi-structured topic schedules guiding conversations on their thinking processes while managing patients with UI. Focus groups to discuss factors influencing PHPTs’ decision-making were undertaken with experienced PHPTs in the UK and KSA. Participants from the UK were invited via the Pelvic Obstructive Gynaecology Physiotherapy association, the area representative of the UK pelvic health physiotherapists. While, the KSA participants were invited via the Saudi Physical Therapy Association, the area representative of KSA pelvic health physiotherapists. Recruitment continued until no new key themes arose for two consecutive interviews and in focus groups, the research was considered to be addressed sufficiently. The interviews and focus groups were transcribed verbatim. A framework analysis approach was used to interpret the data for the exploration of the CR models and the factors that affect the DM of PHPTs. Data collection took place between September 2018 and December 2019.

Forty-eight participants from across both countries took part in interviews and focus groups in each country. The main themes were found; contextual factors (individual and organisational culture), and sense-making theory to understand physiotherapists’ clinical reasoning processes. There were key similarities and differences between KSA and the UK. The impact of these factors on DM and CR varied slightly between the UK and KSA participants due to differences in the cultural and religious context, and organisational culture. The culture was the biggest differentiation between the two countries. UK participants living in culturally diverse places were aware of the significance of considering culture in their management decisions, based on their training, knowledge and experiences of working within a multicultural context. Some participants in the UK also attended a cultural competency program. However, they questioned the benefit of that programme in helping them deal with different ethnicities. Compared to the UK, religion plays a dominant role in KSA culture, which in turn influences healthcare delivery. In the UK however, the religious background of patients does influence how PHPTs decide to provide healthcare to certain patients. The findings suggest that some patients from different ethnic groups or religious backgrounds might be sensitive to digital palpation, and the way PHPTs ask questions might vary due to different beliefs or understandings.

A novel finding of this research is that individual and organisational cultures were more influential in CR than had previously been considered in the general physiotherapy clinical reasoning and DM literature. This finding regarding the importance of individual and organisational cultures was made possible by comparing the UK and the KSA. National and regional identity, as well as religion, shaped patients’ individual cultures in both countries, but there was also the organisational or institutional culture that shaped the physiotherapist's identity and influenced how they made decisions in the face of uncertainty. This was evident in the findings of the current study, which demonstrated that participants in both countries exhibited different understandings and incorporation of culture into their management plans. Some of them did implement this, while others were only showing awareness of those cultural needs and beliefs without considering the impact on management. The present study is the first study to explore the influence of culture on PHPTs’ CR while treating UI patients in different countries. ‘Cultural humility’, introduced by Tervalon and Murray-Garcia (1998), gives a different and deeper perspective on cultural competence through a continuous reflection of one’s self and acknowledgement of the power imbalances between patient and healthcare providers and the challenges of institutional-level barriers. Also, it takes into account the fluidity of culture and challenges both individuals and institutions to address health inequalities (Fisher-Borne, Cain and Martin, 2015). It is not about a certain ethnicity, race, behaviour or belief, but about integrating cultural perspectives into management decisions. It requires physiotherapists to be open about patients’ identities, giving it more weight than their own experience. There is a growing body of literature that has challenged the explicit and implicit assumptions of cultural competency. Some limitations of the cultural competency approach include an over-emphasis and rigidity when it comes to an individuals’ health practitioners’ own opinions. This approach fails to wholly and comprehensively value and incorporates the needs and wishes of an individual patient from a different cultural background. Most of the UK participants were aware of cultural competency as a method of understanding patients’ needs from different ethnicities, but only a few PHPTs were using cultural humility instead. However, cultural competency does not provide a completely tailored solution that fully encompasses and incorporates an individual’s culture, so an increased awareness and understanding of cultural humility among PHPTs may be necessary to help resolve this issue.

This is the first study in PHPTs that explores in-depth CR and DM in two different cultures. The differences identified between the CR of PHPTS in the two countries led to the identification of new findings that recognises the critical impact of individual and organisational culture on PHPTs' sense-making and CR processes. There is an urgent need to consider individual and organisational cultures in any attempts to introduce new evidence or implement clinical guidance, especially among Muslim women and other minor ethnicities. It is highly recommended to implement cultural humility rather than competency in physiotherapists' management of patients of minor ethnicity.

Fisher-Borne, M., Cain, J.M. and Martin, S.L. (2015) 'From mastery to accountability: Cultural humility as an alternative to cultural competence', Social Work Education, 34(2), pp. 165-181.
Tervalon, M. and Murray-Garcia, J. (1998) 'Cultural humility versus cultural competence: A critical distinction in defining physician training outcomes in multicultural education', Journal of health care for the poor and underserved, 9(2), pp. 117-125.
Yoshikawa, K. et al. (2020) 'Sociocultural factors influencing physiotherapy management in culturally and linguistically diverse people with persistent pain: a scoping review', Physiotherapy, 107, pp. 292-305.

Continence 2S2 (2022) 100423
DOI: 10.1016/j.cont.2022.100423