Physiotherapy 99 (2013) 341346

Isnt it all Whites? Ethnic diversity and the physiotherapy profession

Gillian Yeowell
Department of Health Professions, Manchester Metropolitan University, Manchester, UK

Abstract
Aim To explore physiotherapists perceptions, views and experiences of ethnic diversity in relation to the physiotherapy profession.
Design Qualitative research study, drawing on ethnographic traditions and including ethnographic interviews. The interviews were transcribed
verbatim and the data were analysed using thematic analysis. Several verification procedures were incorporated into the design to ensure
quality.
Setting Venues chosen by the participants in North West England.
Participants A purposive sample of 22 physiotherapists (five students, seven clinicians and 10 academics) with a range of ethnicities.
Findings Most participants experiences and perceptions were of a lack of ethnic diversity within the profession. Further findings related to
the impact of this included: the perception that physiotherapy is a White profession; some Black and Minority Ethnic (BME) physiotherapists
felt out of place on occasions; and failure to meet patients needs. The potential benefits of increased ethnic diversity and the possible risks
of valuing BME staff solely in terms of their ethnicity were also illuminated by the findings.
Conclusions This study of the perceptions and experiences of physiotherapists identified a lack of ethnic diversity within the profession. It is
argued that a lack of ethnic diversity may result in a failure to meet patients needs. A workforce that is reflective of the population it serves
can have greater cultural knowledge, and is more likely to understand and respond to patients needs.
2013 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.
Keywords: Ethnic diversity; Black and Minority Ethnic groups; Physiotherapy; Qualitative

Introduction
Physiotherapy has traditionally been considered a White,
female, middle class profession [1,2]. However, government
policy over the past decade has emphasised the need to
increase the diversity of staff and students in relation to health
and higher education [3,4]. It is acknowledged that growth of
staff from Black and Minority Ethnic (BME) backgrounds
has been too slow and that more needs to be done [3,4].
The NHS Plan [4] highlights the need to recruit and retain
BME allied health professionals, as it considers that this will
provide a more effective, accessible and culturally sensitive
service to BME communities and, as such, will be better
placed to meet the needs of its patients. However, despite the
Governments policy to increase the number of students from
Correspondence: Department of Health Professions, Manchester
Metropolitan University, Elizabeth Gaskell Campus, Hathersage Road,
Manchester M13 0JA, UK. Tel.: +44 161 2472961; fax: +44 161 2476328.
E-mail address: g.yeowell@mmu.ac.uk

under-represented groups [3], BME groups on undergraduate

physiotherapy programmes remain poorly represented.
Statistics from the 2011 Census in England and Wales
revealed that 14% of the population were from BME groups
[5]. In contrast, the intake of BME students on to physiotherapy courses nationally in 2010/2011 was just 10% [6].
Moreover, this is significantly below the UK average of 18%
of BME students studying on university programmes in the
same year [7].
Therefore, in light of the limited success of the Governments agenda to increase the diversity of healthcare students
and staff, it is important to explore the perceptions and experiences of physiotherapists in relation to ethnic diversity within
the profession. However, there is a dearth of literature on
this issue. Kai et al. [8] undertook a qualitative study to
explore the experiences and challenges perceived by educators in health, including physiotherapy, in relation to training
health professionals. However, there has been a significant
increase in the ethnic diversity of the UK population since
this study was undertaken [5]. As such, the experiences of

0031-9406/$ see front matter 2013 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.physio.2013.01.004

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G. Yeowell / Physiotherapy 99 (2013) 341346

educators may have changed. More recently, Bogg et al. [9]

undertook a national survey to evaluate physiotherapists personal perceptions of equality and diversity in the National
Health Service (NHS) and within the profession. However,
the study used a quantitative approach, which can limit the
depth and understanding of peoples experiences [10]. Therefore, the aim of the present study was to address this gap,
and to explore physiotherapists perceptions, views and experiences of ethnic diversity in relation to the physiotherapy
profession.

Method
Sample
Participants were recruited from North West England. Purposive sampling was used to select participants who had
specific characteristics or knowledge of the phenomenon of
interest to enable the author to explore the research aim [10].
Participants were included in the study if they were student
physiotherapists or physiotherapists working in the clinical
or academic setting, and were recruited from a range of ethnicities. Physiotherapists who were unable to give informed
consent were excluded. Gatekeepers, who were department
heads within a higher education institution (HEI) or NHS
physiotherapy managers, introduced the author to potential
participants. In order to gain a holistic understanding, the
author purposively selected participants from a range of ethnicities, who had a range of experience in terms of years
studying or working as a physiotherapist, and experience of
working with an ethnically diverse population. Recruitment
of participants continued until data saturation was achieved
[11]. In total, 22 participants took part in this research (see
Table A, supplementary online material).
Study design
A qualitative research design was adopted, as this was the
most appropriate approach to explore the research aim [10].
This involved an interpretative and naturalistic approach to
the subject matter, which drew on ethnographic traditions
[12]. Ethnography is the art and science of describing and
interpreting a culture [11], and as such, was an appropriate
methodology to explore the phenomenon of interest. Ethnographic interviews were used to generate data. The main
features of these interviews are their flexible approach, which
enabled the researcher to focus on issues of importance to
the research aim, whilst allowing participants to discuss the
issues important to them [11].
The author undertook all interviews at venues chosen by
the participants. The interview questions related to the aim
of this study, and provided an insight into peoples thoughts
and experiences. A topic guide was used to guide data generation. The guide began with collecting a biography of the

participants ethnicity and religion in order to provide context for the interview. The topic guide included exploratory
questions about the participants perceptions, views and experiences of ethnic diversity in relation to the physiotherapy
profession (see Table B, supplementary online material).
Subsequent questions were conversational in nature and drew
on what the participant had mentioned in their reply, whilst
remaining focused on the research aim, to ensure sufficient
flexibility to allow the exploration of new and unexpected
issues [13].
Ethnography usually involves a variety of methods to generate data [11]. Having relied chiefly upon interviews for data
generation, the author also observed the participants during
periods throughout their normal working day and at social
gatherings. Furthermore, analysis of existing material in relation to physiotherapy, such as prospectuses, photographs and
meeting minutes, were analysed [10]. This allowed the author
to gain understanding and add meaning to the interviews
that would not have been apparent if interviewing had been
used in isolation. The author undertook a cyclical process of
data generation and analysis following each interview, which
included participant observation data and reflexive memos of
the authors role and how this may have impacted on the process of knowledge construction. This analysis then fed into
the next interview. This article focuses on the data generated
from interviews.
The author used several verification procedures to ensure
the trustworthiness of this research, including prolonged
engagement and observation of the participants, and triangulation of methods and sources of data. Moreover, peer
review was undertaken with two academic researchers (nonphysiotherapists) and two key informants (one academic
physiotherapist and one physiotherapy clinician) from a
range of ethnicities, who asked questions about the emerging
findings and interpretations [10]. Finally, the author considered reflexively her position and biases in the research
that may have impacted on the inquiry. The author is a
White physiotherapy academic. This may have affected
what the participants were willing to disclose, and what
the author foregrounded in terms of data analysis. In cognisance of this, the author ensured that a good rapport was
established with the participants and considered alternative
interpretations of the data, which was facilitated by peer
review.
Ethics
An application to the NHS Research Ethics Committee
and the University Faculty Ethics Committee was submitted, and ethical approval was granted. This included
how the author would protect the dignity, rights, safety
and well-being of the participants by ensuring: protection from harm; voluntary participation; gaining informed
consent; data management and storage; and maintaining
confidentiality and protecting the anonymity of all those
involved.

G. Yeowell / Physiotherapy 99 (2013) 341346

Data analysis
All interviews were digitally recorded and transcribed
verbatim. Analysis was an iterative process, and the data
were returned to again and again to ensure that the findings
were grounded in the data. Data were analysed using thematic analysis, which is a method for identifying, analysing
and reporting patterns or themes within qualitative data [13].
Data transformation was conducted following a six-stage process as described by Braun and Clarke [14]: familiarisation
with the data; generating initial codes; searching for themes;
reviewing themes; defining and naming themes; and writing
up the analysis. The initial stage involved repeated listening to the interview audio files. These were then transcribed
by the author. The process of transcription, whilst time consuming, can be an excellent way to immerse oneself in the
data, and can be considered a key phase of data analysis for
an interpretive paradigm [12]. This was followed by reading and rereading the interview transcripts. The data were
organised into meaningful segments to identify any emerging patterns, and codes were developed [11]. Codes were
combined, reviewed and refined to form subthemes and an
overarching theme [14].

Findings and discussion

Three subthemes emerged in relation to the overarching
theme, Ethnic diversity within physiotherapy: Lack of ethnic diversity, Impact of decreased ethnic diversity and
Potential benefits and risks (see Fig. 1).
Each subtheme is explored below using verbatim quotes
to illuminate the findings. Pseudonyms have been used to
ensure the anonymity of participants.
Lack of ethnic diversity
The majority of physiotherapists interviewed, from their
experience of their physiotherapy training, agreed that the
profession was predominantly a White profession, both historically:
Our physio school was in this very ethnically diverse town
and the physio school was predominantly White middleclass. This was the late 90s. But the university is famed for
its ethnic diversity and its minority studies and so we stuck
out a bit on the campus. (Pat, White academic)
and currently:
And then when I first started university there was, from what
I could tell, only one other Asian on the course and 2 or 3
Black people in my year [approximately 2% of the cohort].
You know its full of White people [laughs]. (Rashmi, BME
student)
This lack of ethnic diversity within physiotherapy training
seems to be borne out in current clinical practice:

.
.
.
.
.
.
.
.
.
.
.

Codes

343
Subthemes

White student
cohort/ethnically
diverse town
Full of White
people
Never seen a Black
physio
Isnt it all Whites?

Lack of ethnic
diversity

Physio only for

White students
Felt out of place
Decreased cultural/
religious knowledge
Decreased empathy

Impact of
decreased
ethnic
diversity

Better educated
about culture and
religion
Insider
understanding
Seen as race
experts
Cultural competence
based on ethnicity

Potential
benefits and
risks

Overarching theme

Ethnic diversity
within
physiotherapy

Fig. 1. Emergent themes in relation to ethnic diversity.

I had one patient who went Ooh wow, Ive never seen a
Black physio before; sorry I didnt mean to offend you. I
said, No, Im Black; Im a physio [laughs]. (Cecile, BME
student)
Whilst current statistics may suggest that ethnic diversity
may be increasing slowly in physiotherapy since the widening
participation agenda [3], the perception remains that it is a
White profession:
But a [White] friend of mine said to me, Why, did you get
in? [putting on a surprised voice], and I said, Cheers for that
yeah, and he said, Yeah but isnt it all Whites?. . .Looking
back theres only me and Lloyd, the Black guy, and Devarish,
on the course. (Masood, BME student)
It appears that the physiotherapy profession recognises
that there is a lack of diversity amongst the student intake:
Its recognising that a lot of our students are 18-year-old
school leavers and a lot of them will have come from quite
a narrow social background. They havent been exposed to
much diversity and its part of going to university. Its about
meeting other people and recognising the value of that for
them as a professional. (Helen, White academic)
It is illuminating that this academic highlights the wider
role of the university in relation to ethnic diversity, which
may suggest she has some insight into cultural issues, which

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G. Yeowell / Physiotherapy 99 (2013) 341346

is supportive of the intention of the Race Relations Amendment Act which states that HEIs have a legal duty to promote
good relations between people of different racial groups
[15].

them and so forth. So if we dont make that effort, all that will
happen is that they wont come back. (Liz, White academic)

Potential benets and risks

Impact of decreased ethnic diversity
Some BME students spoke of how the lack of ethnic diversity within physiotherapy made them feel:
It just sort of made me feel like well is it only White people
that would go into physio. (Rashmi, BME student)
Mason and Sparkes [1] highlighted that a major issue for
minority ethnic students on programmes within HEIs was
that of being the token Black student, which led to feelings
of isolation and of feeling unsupported.
Other students expressed how they felt when there was
some ethnic diversity on the programme:
And Im lucky enough that in my group there was a mixture of ethnicities. . .Im very happy that it was put that
way because I would have felt slightly out of place in the
beginning. . .it just felt comforting to look across the room
and see someone who looks like you. (Cecile, BME student)
These findings resonate with the findings of Beagan [16],
who found that students from minority ethnic groups felt a
connection and a sense of community with other members
of minority ethnic groups on initial meeting, from which
they felt they were able to share similar experiences and gain
support.
This lack of ethnic diversity has been highlighted as a
concern for several reasons, with one of the main arguments
being that as physiotherapists are national providers of health
services, the profession should reflect the ethnicity of the
national population in the UK [17,18]. Due to this, the mission
of the NHS is to ensure that the workforce is reflective of the
community it serves [19]. It can also be argued that a lack
of diversity within a profession can result in the inability to
see things from another cultural perspective [20,21], which
some highlighted as a potential issue for the lack of diversity
within physiotherapy:
Then all of a sudden theyre thrown out into hospitals where
theres all these different types of people and some of them
are shocked, and some of them think, what is going on? What
are they doing that for? Its true because they dont know what
is their culture and religion. (Rana, BME clinician)
Others added that this highlighted how a lack of understanding of other cultures may lead to a lack of empathy,
which, in turn, might lead to a failure to meet the needs of
those from minority ethnic groups:
I dont see how you as a physiotherapist can treat somebody without having those skills of empathy. And you cant
empathise with somebody unless you try your very best to
understand what their life is about and whats important to

Some physiotherapists felt that there would be potential

benefits to having increased ethnic diversity within physiotherapy:
I think, if you increase the number from different backgrounds, you at least increase the chances of a patient meeting
somebody. And, even the profession itself will become better
educated if youve got that mix so, its not just about the one
on one, its about the profession as a whole and educating
each other. (Helen, White academic)
It has been suggested that one of the benefits of increased
ethnic diversity is that the BME professionals will have
heightened cultural awareness, and as such, can provide the
most appropriate care to non-White groups [22]. However,
it can be questioned whether by virtue of membership to a
minority ethnic group, it automatically follows that an individual has greater awareness of different cultures. Rather,
cultural competence depends on knowledge, awareness and
sensitivity to other cultures, regardless of the physiotherapists ethnic background [18]. On the other hand, the
experiences of BME physiotherapists of being in the minority and the disadvantages they may have faced may make
them more sensitive to cultural differences. Further, BME
staff should not be seen as race experts and restricted to one
area of work, such as working solely with non-White patients,
and any tendency to value BME staff solely in terms of this
is erroneous [20,23]:
I treated so many Gujarati people; I shouldnt have to deal
with that whole workload at all. I should also have the experience of dealing with other patients; Black patients, White
patients, Chinese patients, whatever, I should get a diverse
range of patients. I did feel that because I was doing it all the
time that it wasnt fair. (Rashmi, BME student)
Others felt that, as a result of their experience, patients
benefited from increased ethnic diversity:
I think they can identify with me a little bit better. So they
might be a little more comfortable with me. Because its like
a familiar face isnt it, like shes from my side or shes brown
like me. (Seeta, BME clinician)
However, others felt that rather than the ethnicity of the
physiotherapist being important, it is their skills that matter
to the patient:
I think more than having several Black members on your
team, its how you perform that makes a difference. And I
think that if we treat people with respect and consider some
of their needs, I think that actually goes further than one Asian
physio whos actually rude to them. (Mary, White clinician)

G. Yeowell / Physiotherapy 99 (2013) 341346

This perspective seems to be supported by the experience

of an academic who observed a poor intervention by a Muslim
physiotherapist treating a Muslim patient:
I remember a Pakistani woman being treated in front of me
by someone from Dubai, and the Dubai girl did less well
than I would have done in that situation. And they were both
Muslim, so you could say culturally they should have been
on a par. (Emily, White academic)
The above excerpt seems to highlight the complexity of
culture, and the fact that whilst one aspect of their ethnicity was the same religion it should not be assumed
that the therapist was cognisant of and sensitive to other
aspects of the patients culture that might be important to
them.
Limitations of the study
The limitations of using ethnic group categories within this
research are acknowledged, and it is not the authors intention to suggest that the perceptions and experiences of BME
groups and White groups are homogenous. However, ethnic
group categories were used in line with the 2001 Census to
enable the findings of this research to be considered in light
of the wider literature.
Furthermore, it should be acknowledged that interviews
have their limitations in ethnography. Rather than telling the
whole story, the necessary analysis and thereby reduction of
the data results in only part of the story being told.

345

Conclusion
The physiotherapy profession has traditionally been seen
as a White, middle class profession, with recent statistics
suggesting that there continues to be a lack of ethnic
diversity within the profession [6]. Therefore, the aim of
this research was to explore physiotherapists perceptions,
views and experiences of ethnic diversity in relation to the
physiotherapy profession. The findings appear to support
these statistics, with most participants experiences and
perceptions indicating a lack of ethnic diversity within the
profession. Further findings emerged which related to the
impact of this: the potential benefits of increased ethnic
diversity, and the possible risks of valuing BME staff solely
in terms of their ethnicity. Further research is needed to
explore the reasons why students and staff from BME
backgrounds remain under-represented in the profession
today.
Ethical approval: South Manchester REC (No:
05/Q1403/223); Faculty Ethics Committee, Department of
Health Professions, Manchester Metropolitan University.
Funding: The authors doctoral research was funded
by the Department of Health Professions, Manchester
Metropolitan University.
Conict of interest: None declared.

Implications for physiotherapy

Appendix A. Supplementary data

It can be seen from the exploration into the perceptions

and experiences of physiotherapists that there is a lack of
ethnic diversity within the profession. It is of some concern
that the physiotherapy profession in Britain does not reflect
the ethnic and cultural diversity of the population it serves.
It is argued that a lack of ethnic diversity within the profession may affect the ability to see from more than one cultural
perspective [21]. The more ingrained we are in our culture
due to a lack of ethnic diversity, the more this may militate
against more complex thinking on race and cultural issues,
and as such, may result in a failure to meet the needs of the
population we serve, including patients, students and staff.
It is argued, therefore, that a workforce that is reflective of
the community it serves will have greater cultural knowledge, and will be more likely to understand and respond to
the local community [18,24]. Having an ethnically diverse
workforce has been credited with other positive outcomes,
such as increasing trust in public institutions to improving the
quality of services provided by virtue of greater understanding and sensitivity, and creating a sense of community with
other members of BME groups [25]. Furthermore, drawing
from BME groups will enable the profession to select from
a larger pool of talent.

Supplementary material related to this article found, in the

online version, at http://dx.doi.org/10.1016/j.physio.2013.
01.004.

References
[1] Mason C, Sparkes VJ. Widening participation in physiotherapy education. Physiotherapy 2002;88:27684.
[2] Nicholls DA, Cheek J. Physiotherapy and the shadow of prostitution:
the society of trained masseuses and the massage scandals of 1894. Soc
Sci Med 2006;62:233648.
[3] Department for Education and Skills. Widening participation in higher
education. London: HMSO; 2003.
[4] Department of Health. NHS plan (Cm4818-l). London: Department of
Health; 2000.
[5] Office for National Statistics. Ethnicity and national identity in England and Wales 2011. 2012. Available at:
http://www.ons.gov.uk/ons/dcp171776 290558.pdf (last accessed
17.12.12).
[6] Chartered Society of Physiotherapy. Annual quality review of UK qualifying physiotherapy education 2010/11. London: Chartered Society of
Physiotherapy; 2011.
[7] Higher Education Statistics Agency. Statistics and qualifiers at
UK HE institutions: ethnicity of UK domiciled students. 2012.

346

[8]
[9]

[10]
[11]
[12]
[13]
[14]
[15]
[16]
[17]

G. Yeowell / Physiotherapy 99 (2013) 341346

Available at: http://www.hesa.ac.uk/content/view/1897/239/ (last
accessed 17.12.12).
Kai J, Spencer J, Woodward N. Wrestling with ethnic diversity: toward
empowering health educators. Med Educ 2001;35:26271.
Bogg J, Pontin E, Gibbons C, Sartain S. Physiotherapists perceptions of equality and career progression in the NHS. Physiotherapy
2007;93:13743.
Maxwell JA. Qualitative research design: an interactive approach. 2nd
ed. Thousand Oaks: Sage; 2005.
Atkinson P, Hammersley M. Ethnography: principles in practice. 3rd
ed. Oxon: Routledge; 2007.
Denzin NK, Lincoln YS. Handbook of qualitative research. Newbury
Park: Sage; 1994.
Silverman D. Interpreting qualitative data: methods for analysing talk,
text and interaction. London: Sage; 1993.
Braun V, Clarke V. Using thematic analysis in psychology. Qual Res
Psychol 2006;3:77101.
Race Relations (Amendment) Act. Race Relations (Amendment) Act
2000. London: HMSO; 2000.
Beagan BL. Is this worth getting into a big fuss over? Everyday racism
in medical school. Med Educ 2003;37:85260.
Greenwood N, Bithell C. Perceptions of physiotherapy compared with
nursing and medicine amongst minority ethnic and white UK students:
implications for recruitment. Physiotherapy 2005;91:6978.

[18] Chartered Society of Physiotherapy. Equality and diversity toolkit: a

practical guide for CSP stewards, managers and members. London:
Chartered Society of Physiotherapy; 2010.
[19] Department of Health. The NHS Knowledge and Skills Framework
(NHS KSF) and the development review process. 2004. Available
at: http://www.dh.gov.uk/prod consum dh/groups/dh digitalassets/@
(last
accessed
dh/@en/documents/digitalasset/dh 4090861.pdf
20.03.12).
[20] Andrews M, Boyle JS. Transcultural concepts in nursing care. 5th ed.
Philadelphia: Lippincott Williams and Wilkins; 2007.
[21] Pearce S. You wouldnt understand: White teachers in multiethnic
classrooms. Stoke-on-Trent: Trentham Books; 2005.
[22] Moore V, Beitman L, Rajan S, Dandrea J, Nicolosi J, Shepard K,
et al. Comparison of recruitment, selection and retention factors:
students from under-represented and predominately represented backgrounds seeking careers in physical therapy. J Phys Ther Educ 2003;17:
5566.
[23] French S. Health care in a multi-ethnic society. Physiotherapy
1992;78:17480.
[24] Department of Health. Equalities and diversity strategy & delivery plan
to support the NHS. London: Department of Health; 2003.
[25] Johns N. Ethnic diversity policy: perceptions within the NHS. Soc
Policy Admin 2004;38:7388.

Available online at www.sciencedirect.com