Mental health education for physiotherapists: A scoping review

Background Physiotherapists play an integral role in the management of people living with a mental illness, yet little is known about their knowledge, attitudes and perceptions about mental health globally and particularly in South Africa. Aim The purpose of the study is to map global evidence on mental health education for physiotherapists, including their knowledge, attitude and perceptions, with the goal of using this information to design an improved undergraduate curriculum for physiotherapy in South Africa. Setting The search was focused on the South African and global context, with the participants as physiotherapists and physiotherapy students. Methods The methodical framework proposed by Arksey and O’Malleys guided the scoping review. The online search used five electronic databases. An expert librarian assisted in the search strategy. English language, primary research articles that investigated physiotherapist or physiotherapy students’ knowledge, attitude and perceptions towards mental health were sought. Results The search strategy extracted 226 published studies and 15 studies were included in the analysis. The results indicated that globally physiotherapists and physiotherapy students had limited knowledge about mental health. Improved attitudes were noted with a mental health training intervention. Negative perceptions were associated with limited knowledge. Conclusion There was limited literature on the influence of education on mental health in physiotherapy on attitudes and perceptions. Physiotherapists desired more knowledge about mental health because of the prevalence of mental health disorders. Contribution Because of the increasing prevalence of mental illness globally, the findings of this review suggest the necessity of integrating mental health content in the physiotherapists’ undergraduate programme to provide high-quality care physiotherapy management for people with mental illnesses.


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Introduction
One in six South Africans suffer from depression, anxiety or substance use disorders, and 40% of South Africans with human immunodeficiency virus (HIV) have a mental illness. 1 The mental health crisis in South Africa is in dire need of change, with a lack of access and poor quality of mental health services. 2According to the Lancet Commission Report on Mental Health and Sustainable Development, the lack of mental health services is not unique to South Africa.Mental health services have been neglected globally. 3The quality of mental health services is worse than the quality of services for physical health. 3An integrated collaboration care model for people living with mental illness (PLWMI) and physical comorbidities can improve both mental and physical health outcomes with a patient-centred approach. 4ysiotherapy is a healthcare profession that deals with human movement and maximising functional physical potential.Physiotherapists use promotion, prevention, treatment interventions and rehabilitation strategies to promote, maintain and restore patients' physical, psychological and social well-being. 5The key components of physiotherapy management in mental health include health promotion, preventive healthcare, treatment and rehabilitation for individuals or groups.Physiotherapeutic interventions include exercise, physical activity (PA), relaxation therapy, basic body awareness therapy (BBAT) and touch therapy. 6They create a therapeutic relationship in a supportive environment by applying the biopsychosocial model, with the goal of http://www.sajpsychiatry.orgOpen Access promoting functional movement, movement awareness, PA and exercises, bringing together the mental and physical aspects. 7The biopsychosocial model of health considers the biological (genetics, injury, disease, exercise, diet), social (family, school, relationship, poverty) and psychological (feelings, emotional intelligence, behaviour, beliefs) factors that affect the treatment outcomes. 8,9The scope of practice allows physiotherapists to manage patients with physical conditions and use the biopsychosocial approach in a personcentred manner.An integrated collaboration care model for PLWMI and physical comorbidities can improve both mental and physical health outcomes with a patient-centred approach. 4Bridging the collaborative gap between mental and physical health can be accomplished by improving access to care, reducing stigma and promoting policy of integrating physical and mental healthcare. 10rong evidence exists to support the link between physical and mental health. 11,12,13,14Prince et al. (2000) further stated that the relationship between physical and mental health is very evident in patients with HIV, cardiovascular disease and diabetes.Physiotherapy in mental health is often regarded as insignificant in the management of PLWMI, and the role and value are unclear among the members of the multidisciplinary team (MDT). 15However, physiotherapy interventions complement medication and psychotherapy. 16The intervention of physiotherapists, which is associated with increased PA, can greatly enhance the quality of life for people with serious mental illness (SMI). 17In addition, physiotherapists (PT) can play an important role in addressing psychological factors when they are involved in the treatment and rehabilitation process of persons with disabilities, thereby enhancing rehabilitation outcomes. 18The role of the physiotherapist in the psychiatric MDT is to act as a bridge between physical and mental health and they are integral in providing treatment for the physical health for PLWMI. 19e major barrier to physiotherapists' delivery of quality of care to PLWMI is stigma.Probst and Skjaerven 6 defined stigma as a mark of disgrace.Stigma is primarily observed in mental health.The definition of stigma is quite complex, and it is linked to a trait, involves negative judgement, is social rather than personal, does not reside with a person or attribute but is created in interaction with others and is not static. 20Stigma increases the burden on mental health disorders and affects community members, families of PLWMI and medical professionals. 21Stigmatised attitude and lack of knowledge can have a negative influence on interactions with PLWMI. 22Tessem et al. 23 stated that supervised student practice enhances communication and being sensitive to PLWMI, they adapted to challenging situations and found solutions through critical reflection on stigmatising attitudes and behaviours.
People living with mental illness have a higher prevalence of metabolic syndromes than the rest of the population in sub-Saharan Africa. 24Metabolic syndromes (MetS) consist of a cluster of conditions including abdominal obesity, diabetes, dyslipidaemia and hypertension.Patients with MetS have a greater risk for reduced PA performance. 25Bridging the collaborative gap between mental and physical health can be accomplished by improving access to care, reducing stigma and promoting a policy of integrating physical and mental healthcare. 10Consequently, incorporating modules on mental health during undergraduate physiotherapy training would be a good way to start.
There is a dearth of literature globally about the influence of education on mental health in physiotherapy on attitudes and perceptions.Providing mental health education for physiotherapy students in the undergraduate programme or postgraduate level would greatly enhance the skills of future physiotherapists. 26Negative stereotypes, attitudes and perceptions of mental illness can compromise access of PLWMI to physiotherapy services. 26Education and direct contact with PLWMI can assist to combat the problem of stigmatisation and other obstacles to their access to quality physical healthcare. 27,28,29is study aims to map the existing literature in South Africa and globally on the influence of mental health education on the knowledge, attitudes and perceptions of physiotherapists and physiotherapy students using a scoping review approach.There is no scoping review conducted to date that has explored the knowledge, attitudes and perceptions of physiotherapists or physiotherapy students regarding mental health.The study also aims to gain insight into future framework design for the inclusion of mental health in the undergraduate physiotherapy programme.

Methods
A scoping review was conducted following the five steps outlined by Arksey and O'Malley in their methodological framework. 30In accordance with this framework, the five steps used were identifying the research question; identifying relevant studies; study selection; charting the data and collating, summarising and reporting results.

Identification of the research question
The overall aim of the study underpinning the scoping review was: 'What influence does the education on mental health in the physiotherapy undergraduate programme have on the knowledge, attitude and perceptions of physiotherapists and physiotherapy students?'The research questions were identified as follows: 1. Is mental health content included in the physiotherapy undergraduate curriculum in South Africa and globally?2. Does knowledge about mental health influence the attitudes and perceptions of physiotherapists and physiotherapy students?3. What is the importance of mental health content in the physiotherapy undergraduate programme?4. Is the knowledge gained through the physiotherapy undergraduate programme adequate for physiotherapists to manage PLWMI?
The population, concept and context (PCC) for the study are defined in Table 1.

Ethical considerations
The researchers obtained ethical approval from the Humanities and Social Sciences Research Ethics Committee, HSSREC, of the University of KwaZulu-Natal ethical committee (ethical approval number: HSSREC/00004701/2022).

Identifying relevant studies
The following electronic databases were used to conduct a search for literature:

Eligibility criteria
The PCC framework was used to select the appropriate research articles.The inclusion and exclusion criteria were developed to identify key areas of interest.Table 2 outlines the inclusion and exclusion criteria.

Study selection
Eligible articles were identified and uploaded to the citation manager, Mendeley v2.80.1, and all duplicate articles were removed.Two independent reviewers screened the titles and abstracts as well as the full text screening of retrieved articles that were relevant to the research objectives.A third reviewer screened any excluded citations and resolved any differences between the two reviewers to make a final decision.The library service at the University of KwaZulu-Natal was used to access full text articles that were not open-access publications.

Charting data
Data from the selected studies were extracted and recorded in a standardised data abstraction tool designed.The following data were extracted to answer the study's question: • Participant characteristics: sample population and gender (Table 3).• Study characteristics: author information and publication year, aim/objectives of the study, setting or location of the study (Table 4).
• Findings: tools used to quantify knowledge, attitudes and perceptions, the mental health content training (Table 4).• Outcomes and conclusions: relevant to the study's objectives.

Collating, summarising and reporting the results
To answer the study question, all the relevant data were summarised.The results of the study selection were presented in a flowchart diagram and a narrative summary of the finding has been presented. 31The Mixed Methods Appraisal Tool (MMAT) version 2018 was used to appraise the quality of the selected studies 32 (Appendix 1).

Study characteristics
Initial search strategies as described resulted in 226 studies being identified from the database searches.Studies were screened and a total of 128 duplicated studies were removed.Subsequently, 98 studies were further screened and 78 articles did not meet the inclusion criteria and were therefore excluded from the review (Figure 1).
The search produced 15 studies eligible for the scoping review.Table 3 summarises the study characteristics.Seven articles used a mixed-methods approach, four articles used a quantitative descriptive study approach, two articles used the qualitative study design and the remaining two studies used a quantitative randomised approach.Table 4 describes the study characteristics and the findings of the 15 studies; the study participants of the 9 studies were physiotherapists and the remainder (n = 6) were physiotherapy students.The majority of the participants in all 15 studies were female.Four studies were conducted within Australia.One study selected was conducted in the province of KwaZulu-Natal, South Africa.The themes of knowledge, attitude and behaviour regarding mental health were identified.

Review findings
Fifteen studies highlighted that there was limited training on mental health in the physiotherapy undergraduate programme. 26,33,34,35,36,37,38,39,40,41,42,43,44,45There was consensus among the studies that there is a need for more education about mental health.Participants specified areas of training about mental health that is of importance to them to effectively manage PLWMI (Figure 2).Areas of training included signs, symptoms and pathophysiology of mental health conditions, psychiatric medications and  Four studies showed results on the effect of knowledge on attitudes, and participants exhibited positive attitudes towards psychiatry after completing training related to mental health. 34,40,42,43One study investigated the students' knowledge using the ATP-30 tool to assess attitude after completing mental health training; even though the students' attitudes were more positive than the medical students, it is unclear whether the training influenced a positive attitude. 43Probst and Peuskens 43 study focused on the effect of a 67 h course on psychiatric rehabilitation on the students' attitudes towards psychiatry.The study showed that the second year students had a significantly more positive attitude after the psychiatric rehabilitation course.The ATP-30 tool was used pre-and post-test, and therefore the knowledge gained through the training was shown to influence attitude positively.Karyczak et al. 40       An experimental quantitative study Questionnaire using the ATP-30 tool ATP-30 scores for the entire group of students were moderately positive (104.5).Non-medical students scored higher than PT students.Female students scored significantly higher than males.Students with experience in psychiatry scored significantly higher than those without experience.Second year students scored significantly higher after completing the psychiatric course than the first year that did not receive any training.Second year students that passed the course showed higher ATP-30 scores than those students that failed the course.Students showed a moderately positive belief towards mental illness.Males and female scores were significantly the same.There were no significant differences in scores according to the year of studying.No difference in scores between students that had exposure of students that had a mental problem that required treatment or consultation with a professional and those that did not have any exposure to a mental health problem.Students that had a relationship with a PLWMI had a more positive belief towards mental illness.
PTs need to be familiar with mental health both clinically and for research purposes and therefore institutions should plan new curricula training that will include courses and/or lecture and practical learning that will be related to psychiatry and mental health.
gained, participants' competence and skills were improved, and they had more confidence in managing individuals with SMI.Overmeer et al. 42 focused on the psychosocial factors that affect pain by using a pre-and post-test design.People with chronic pain have a risk of developing mental health problems; it affects their sleep and increases stress and can lead to depression. 46The study found significant changes in the knowledge, attitude, beliefs and skills of physiotherapists after the course, and this was the only study that involved postgraduate training for physiotherapists.One study showed that a lack of exposure to psychiatry was the reason for the physiotherapists' neutral attitude towards mental health and psychiatry. 44The participants were majority female, and 4 of the 15 studies showed that females had a more positive attitude than their male counterparts.Some common themes of perceptions are depicted in Figure 3.Some perceptions noted by participants were their neglect of psychological complaints, negative stereotypes, stigmatising behaviour, fear of safety and reluctance to work in a psychiatric hospital.Perceptions can be influenced by exposure to PLWMI.Physiotherapists that had limited knowledge perceived mental healthcare users (MHCUs) as a potential threat and tended to rely on their own personal beliefs.Table 5 describes the barriers and facilitators to managing PLWMI.The benefits of training on psychosocial strategies are increased knowledge, improvement in the assessment and management of psychosocial issues and the patients' benefit.

Discussion
Knowledge can foster positive attitudes as proven in four studies with an intervention that involved mental health training. 34,40,42,43The four studies showed a considerable improvement in the attitudes of the physiotherapy students after the implementation of mental health training; therefore, the influence of education was positive on the attitudes of the students.Positive attitudes can foster empathy, reduce stigma, improve communication and enable physiotherapists to provide an integrated approach of care for PLWMI.
The reviewed studies did show physiotherapists and physiotherapy students having a positive attitude even though they self-reported having limited knowledge about mental health and psychiatry. 26,33,35,36,37,38,39,41,44,45Education on mental health can complement the positive attitudes by increasing their confidence, understanding, collaboration and capacity to provide holistic care.This will benefit the physiotherapists and PLWMI.Only a study conducted in South Africa noted that physiotherapists reported limited knowledge about mental health and highlighted the need for more education either in the undergraduate or postgraduate programme as they are encountering PLWMI with physical conditions. 39Participants gained their knowledge about mental health from colleagues of the MDT and from years of working experience.Belgium, Norway, Sweden and many European countries offer a programme in the area of physiotherapy in mental health, but it is unclear whether this is being done in any of the other provinces in South Africa except KwaZulu-Natal. 36The role of physiotherapy in mental health is evident, but there needs to be a strengthening of skills and knowledge to meet the needs of PLWMI. 33ducation about mental health can act as an enabler to improving access to physiotherapy services, but limited knowledge and skills are seen as a barrier as physiotherapists tend to avoid the management of patients with conditions that are unfamiliar to them. 26It is evident that there is a disparity in the training being received at various universities globally.The review did not uncover a clear description of the mental health content in the physiotherapy undergraduate curriculum in South Africa and globally.
Adequate knowledge and positive attitudes can greatly reduce stigma.Negative perceptions and stereotypes lead to stigmatising behaviour.A perception that all MHCUs are volatile and dangerous can greatly affect access to care.
Studies have shown that participants had a positive attitude towards psychiatry and mental health, yet they had negative perceptions and limited knowledge. 33,39Initiatives that can improve negative perceptions include engaging in direct interactions with MHCUs and providing education about mental health. 33Attitude is affected by knowledge gained and therefore attitude can influence behaviour. 47Because of the prevalence of mental illness and the limited knowledge of physiotherapists about mental health, physiotherapists had resorted to other avenues to bridge the knowledge gap so they may deliver an efficient and effective service to PLWMI.The inclusion of mental health training in the undergraduate training and postgraduate courses will reinforce the biopsychosocial model of approach to all patients.Training will benefit physiotherapists in managing patients holistically with mental illness and physical conditions.Attitudes are also influenced positively by knowing an individual with mental illness, having consulted a mental health professional or the increased frequency of managing PLWMI. 35,36,39More clinical experience influenced attitudes more positively.Clinical experience with patient interaction can deter negative stereotypes and perceptions. 26sic knowledge about mental health and mental illnesses would greatly improve attitudes.Negative attitudes after graduation may not do justice to PLWMI in general, as psychological factors play an important role in rehabilitation of physical disorders. 31A well-planned course on mental health for physiotherapy students shows significant improvements in beliefs and attitudes but more so on knowledge and skill providing a mutual benefit for the student and the patient. 34,40Because of the growing prevalence of mental illness and comorbidities globally, physiotherapists are managing PLWMI.Consequently, it is essential that they receive education about mental health conditions and the role of physiotherapy in mental health in the undergraduate programme. 35,36,39,48The perception that all MHCUs are violently aggressive is perpetuated by social media. 39,49Mental health awareness education can reduce stigma and kerb the fear of interacting with MHCUs, which is one of the ways to facilitate the management of PLWMI 38 as seen in Table 5.

Limitations
The researcher focused on the influence of education on mental health on knowledge, attitudes and perceptions of physiotherapist and physiotherapy students; well-known electronic databases were used to conduct the search.Although the scoping review applied a rigorous and systematic search strategy, that identified several studies; it is acknowledged that some relevant studies might have been omitted as they were published in other languages besides English.Many of the studies used different outcome measures and study designs and this made it difficult to compare studies.There were inconsistencies in the outcome measures of the studies, and these show a

Conclusion
To our knowledge this is the first review that explored published research about the influence of mental health training in the physiotherapy undergraduate programme has on knowledge, attitude and perceptions of physiotherapists and physiotherapy students.There was one study conducted in South Africa, which found similar results as the international studies showing limited knowledge and underpreparedness of physiotherapists to manage PLWMI.Knowledge was acquired through learning experiences, inservice training and interactions with members of the MDT.These studies also found common findings about attitude and perceptions.Limited knowledge about mental health did not affect attitude, as physiotherapists and physiotherapy students showed a positive attitude.Knowledge, however, had an influence on perceptions, beliefs and views about mental health.Perceptions were negative and depicted by personal experiences and social media.This leads to increased stigma and the forming of barriers to care.Physiotherapy students require a good foundation about their role in mental health and emphasising the biopsychosocial model.Because interventions of mental health training were associated with improved attitudes, it is therefore logical to assume that optimal foundation regarding mental health can engender a more positive attitude in physiotherapists and highlighting the importance of mental health content in the undergraduate programme.Many of the studies showed the limited mental health content.There is an increase in prevalence of mental health disorders globally, and there is a need for the integration of mental health content in the undergraduate curriculum.The scoping review recommends the review of physiotherapy curriculum to include mental health content.

TABLE 1 :
Population, concept and context framework for the main review question.

TABLE 3
continues on next page → http://www.sajpsychiatry.orgOpen Access their side effects, physiotherapists' scope of practice, physiotherapy interventions, the role of other members of the MDT and referral pathways.Skills training was conducted through didactic (lectures/, online modules/, reading) and interactive (practice/, case studies/, faceto-face) methods.

TABLE 4 (
Continues…): Study characteristics and findings of the 15 studies.

TABLE 4 (
Continues…): Study characteristics and findings of the 15 studies.

TABLE 5 :
Barriers and facilitators to managing people living with mental illness.
http://www.sajpsychiatry.orgOpen Access discrepancy in the use of following gold standards for physiotherapy.