About the Author(s)

Marilyn Hooblaul Email symbol
Faculty of Physiotherapy, Ekuhlengeni Psychiatric Hospital, KwaZulu-Natal Department of Health, Umbogintwini, South Africa

Thayananthee Nadasan symbol
Department of Physiotherapy, Faculty of Health Sciences, University of KwaZulu-Natal, Durban, South Africa

Olagbegi M. Oladapo symbol
Department of Physiotherapy, Faculty of Health Sciences, University of KwaZulu-Natal, Durban, South Africa


Hooblaul M, Nadasan T, Oladapo OM. Mental health education for physiotherapists: A scoping review. S Afr J Psychiat. 2023;29(0), a2127. https://doi.org/10.4102/sajpsychiatry.v29i0.2127

Review Article

Mental health education for physiotherapists: A scoping review

Marilyn Hooblaul, Thayananthee Nadasan, Olagbegi M. Oladapo

Received: 12 June 2023; Accepted: 21 Oct. 2023; Published: 01 Dec. 2023

Copyright: © 2023. The Author(s). Licensee: AOSIS.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


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.

Keywords: mental health; physiotherapy; knowledge; attitude; perceptions.


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.2 According 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.3 The quality of mental health services is worse than the quality of services for physical health.3 An 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.4

Physiotherapy 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.5 The 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.6 They create a therapeutic relationship in a supportive environment by applying the biopsychosocial model, with the goal of promoting functional movement, movement awareness, PA and exercises, bringing together the mental and physical aspects.7 The 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.8,9 The scope of practice allows physiotherapists to manage patients with physical conditions and use the biopsychosocial approach in a person-centred manner. An integrated collaboration care model for PLWMI and physical comorbidities can improve both mental and physical health outcomes with a patient-centred approach.4 Bridging 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.10

Strong evidence exists to support the link between physical and mental health.11,12,13,14 Prince 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).15 However, physiotherapy interventions complement medication and psychotherapy.16 The intervention of physiotherapists, which is associated with increased PA, can greatly enhance the quality of life for people with serious mental illness (SMI).17 In 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.18 The 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.19

One major barrier to physiotherapists’ delivery of quality of care to PLWMI is stigma. Probst and Skjaerven6 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.20 Stigma increases the burden on mental health disorders and affects community members, families of PLWMI and medical professionals.21 Stigmatised attitude and lack of knowledge can have a negative influence on interactions with PLWMI.22 Tessem 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.24 Metabolic 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.25 Bridging 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.10 Consequently, 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.26 Negative stereotypes, attitudes and perceptions of mental illness can compromise access of PLWMI to physiotherapy services.26 Education and direct contact with PLWMI can assist to combat the problem of stigmatisation and other obstacles to their access to quality physical healthcare.27,28,29

This 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.


A scoping review was conducted following the five steps outlined by Arksey and O’Malley in their methodological framework.30 In 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.

TABLE 1: Population, concept and context framework for the main review question.
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: Google Scholar, PubMed, Cochrane Library, Web of Science and MEDLINE from 01 January 2000 to 18 October 2022. A search strategy was conducted in consultation with an expert librarian, using the following keywords: ‘physiotherapy’, ‘physical therapy’, ‘physiotherapist’, ‘physiotherapy student’, ‘mental health’, ‘mental illness’, ‘psychological distress’, ‘psychiatric illness’, ‘psychiatry’, ‘undergraduate programme’, ‘training’, ‘curriculum’, ‘knowledge’, ‘beliefs’, ‘perceptions’, ‘beliefs’, ‘views’, ‘behaviour’ and ‘attitude’. Boolean terms ‘AND’, ‘OR’ and ‘NOT’ were used to separate keywords. An expert librarian at the University of KwaZulu-Natal was consulted during the literature search. Mendeley Reference Manager v2.80.1 was used to manage all the citations.

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.

TABLE 2: 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.
TABLE 3: Participant characteristics for the 15 studies.
TABLE 3 (Continues…): Participant characteristics for the 15 studies.
TABLE 4: Study characteristics and findings of the 15 studies.
TABLE 4 (Continues…): Study characteristics and findings of the 15 studies.
TABLE 4 (Continues…): Study characteristics and findings of the 15 studies.
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.31 The Mixed Methods Appraisal Tool (MMAT) version 2018 was used to appraise the quality of the selected studies32 (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).

FIGURE 1: PRISMA flow diagram for the scoping review process.

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.26,33,34,35,36,37,38,39,40,41,42,43,44,45 There 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 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/, face-to-face) methods.

FIGURE 2: Knowledge about mental health.

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.34,40,42,43 One 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.43 Probst and Peuskens43 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 conducted a semi-structured interview with students after attending an 8-week service learning with individuals with SMI. The study showed that because of the knowledge 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.46 The 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.44 The 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.

FIGURE 3: Perceptions about mental health.

TABLE 5: Barriers and facilitators to managing people living with mental illness.


Knowledge can foster positive attitudes as proven in four studies with an intervention that involved mental health training.34,40,42,43 The 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.26,33,35,36,37,38,39,41,44,45 Education 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.39 Participants 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.36 The 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.33 Education 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.26 It 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.33,39 Initiatives that can improve negative perceptions include engaging in direct interactions with MHCUs and providing education about mental health.33 Attitude is affected by knowledge gained and therefore attitude can influence behaviour.47 Because 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.35,36,39 More clinical experience influenced attitudes more positively. Clinical experience with patient interaction can deter negative stereotypes and perceptions.26

Basic 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.31 A 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.34,40 Because 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.35,36,39,48 The perception that all MHCUs are violently aggressive is perpetuated by social media.39,49 Mental 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 PLWMI38 as seen in Table 5.


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 discrepancy in the use of following gold standards for physiotherapy.


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, in-service 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.


The authors would like to thank Mr. Dhanraj Hurriparsad and Prof. Cobbing for their assistance in the study.

Competing interests

The authors declare that they have no financial or personal relationship(s) that may have inappropriately influenced them in writing this article.

Authors’ contributions

The first author M.H. was responsible for the conceptualisation, development of study protocol, collected the data and wrote the manuscript. The co-authors T.N. and O.M.O. provided guidance throughout the study protocol and reviewed the manuscript. All authors read and approved the final manuscript.

Funding information

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

Data availability

Data sharing does not apply to this article as no new data were created or analysed in this study.


The views, opinions, assumptions or any other information presented in this manuscript are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors.


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Appendix 1

FIGURE 1-A1: Mixed Methods Appraisal Tool critical appraisal checklist.

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