A scoping review was undertaken to address the objectives of the study. A broad search using the Joanna Briggs Institute (JBI) Manual for Evidence Synthesis was utilised [8] .

The search strategy employed in this scoping review was designed to comprehensively identify barriers and facilitators to evidence-based practice among physiotherapists in SSA. The following outlines the step-by-step approach taken, detailing the specific search terms used, their alignment with database syntax and the rationale behind each step. The process involved three key stages:

1) Initial Database Search

An initial database search was conducted using the PEDro and Cochrane databases. We accessed the MeSH (Medical Subject Subheadings) database on PubMed and the key terms and free-text keywords included “Evidence-based practice”, “Research”, “Physiotherapy”, “Barriers”, “Facilitators”, “Enablers”, “Sub-Saharan Africa” and “Africa”. We reviewed the suggestions provided within the MeSH database to refine our search strategy.

We utilised the simple and advanced search features to establish extensive search criteria. The following Boolean operators were applied:

The articles were then reviewed for additional MeSH terms that enhanced our understanding of barriers and facilitators in EBP among physiotherapists. During this stage, we were able to identify some common themes. Common barriers identified included lack of time and resources, as well as limited research skills. Facilitators noted included positive attitudes and beliefs.

2) Comprehensive Search in Additional Databases

Following the initial searches, all identified keywords and search terms were used to conduct a second search performed across multiple databases to ensure a broad capture of relevant literature. We searched PubMed, Sabinet and BioMed Central in full.

3) Reference list screening

To further expand the scope of identified literature, reference lists of all retrieved articles were meticulously reviewed. This step aimed to uncover additional studies that may not have been captured in the initial database searches. Each reference was assessed for relevance based on inclusion criteria established prior to this review process.

Data extraction was guided by the Arksey and O’Malley framework and adhered to the PRISMA-ScR reporting guidelines to ensure comprehensive and transparent findings. The Arksey and O’Malley framework for extracting data includes 1) identifying the research question; 2) identifying relevant studies; 3) selecting studies; 4) charting the data; 5) collating, summarising and reporting results; and 6) consulting with stakeholders (optional) [9] . This framework was chosen for its systematic approach to scoping reviews, which aligns well with our objective of exploring barriers and facilitators to evidence-based practice among physiotherapists in sub-Saharan Africa.

After closely reading the sample of studies, we developed a pre-existing framework to identify key themes, which were organised into 3 categories: 1) practitioner factors, 2) organisational factors, and 3) extra organisational factors influencing the utilisation of evidence-based practice among physiotherapists practising in sub-Saharan Africa. The pre-existing framework provided in Appendix 1 (details available in Table A1 ) was piloted prior to ensure its relevance and applicability across the selected studies.

Table A2 , a data extraction evidence table (Appendix 2) was designed to present evidence from the data search and the number of records retrieved from each search. Using an iterative process, data extraction was completed by two authors (LS, AM). The iterative process involved multiple rounds of extraction where initial findings were discussed and refined. This allowed for adjustments in the framework as new insights emerged from the data. To ensure reliability and consistency, any conflicts that arose during data extraction were resolved through discussion between the two authors. If a consensus could not be reached after thorough deliberation, a third author (DD) was consulted to provide an independent review of the conflicting items. This approach not only enhanced the reliability of our findings but also ensured that multiple perspectives were considered in the data extraction process.

The data extraction items were compiled into a structured form, allowing for systematic collection of relevant information. Rigorous checks were implemented throughout this process to maintain consistency and accuracy in data handling. Each extracted item was cross-verified against original study findings to ensure fidelity in representation. Additionally, regular meetings were held among authors to discuss progress and address any emerging issues related to data interpretation or extraction methodology.

The included studies were categorised according to the National Health and Medical Research Council (NHMRC) hierarchy of evidence [10] . All studies included in this review were cross-sectional or utilised an exploratory, descriptive qualitative design, providing a comprehensive snapshot of the barriers and facilitators to evidence-based practice among physiotherapists in sub-Saharan Africa.

The NHMRC hierarchy established a framework for evaluating potential bias within the included studies. This framework allowed for a systematic assessment of the quality of evidence, ensuring that the findings accurately reflect the current state of knowledge regarding barriers and facilitators in this context.

Notably, the findings related to barriers and facilitators were reported exclusively at the practitioner and organisational levels. There were no corresponding facilitators or barriers at the extra organisational level identified in any of the 7 studies included in this paper.

This table presents a comprehensive overview of the seven studies included in our review, focusing on barriers and facilitators to evidence-based practice among physiotherapists in sub-Saharan Africa. Each row details key characteristics of the studies, including:

We combined similar items into overarching categories to enhance clarity and coherence in the findings. For example, “ease of use of outcomes measures” and “knowledge of use of CPGs” were combined as one and placed under the “knowledge” section of practitioner facilitators, while items like ‘belief that use of CPGs impedes critical decision” and “ease of accessing CPGs increases the workload of an already busy schedule” were combined to represent “negative attitudes” towards the implementation of EBP ( Graphs 1 - 4 ).

Practitioner Level Facilitators:

1) Knowledge

2) Attitudes and beliefs

3) Professional development factors

4) Outcome measure awareness/access

physiotherapists across different regions of sub-Saharan Africa. In summary, common barriers to EBP identified in the studies conducted in Kenya, Nigeria, and Ghana included a lack of ability to conduct research, apply findings, or understand statistics. Facilitators noted in Nigeria and Ghana included higher education levels, more years of work experience, and additional education on evidence-based practice (EBP).

In Cameroon and Zimbabwe, similar facilitators were reported, such as positive attitudes towards EBP and knowledge of research methodologies. However, both countries also faced barriers like insufficient time and lack of training in EBP. Notably, Benin presented unique findings, highlighting the non-sensitivity of measures to patients’ cultural and ethnic characteristics as a barrier, while also reporting positive outcomes from the use of outcome measures in practice as organisational facilitators. In South Africa, some unique facilitators also stood out, including availability of incentives, technology and pocket cards/light versions of CPGs and guideline champions. The South African study also indicated that some factors can pose as both barriers and facilitators. In this study, these factors were stakeholder by-in, ease of accessing CPGs, professional culture, patient-centred care. The study also reported the presence of both positive and negative attitudes.

Overall, all studies consistently reported lack of time and inadequate resources as significant barriers. Additionally, Cameroon identified organisational support as a facilitator, while no extra organisational facilitators or barriers were reported (or investigated) across any of the studies.

The implementation of Evidence-Based Practice (EBP) among physiotherapists in Sub-Saharan Africa (SSA) is influenced by a complex array of barriers that vary across different contexts, significantly impeding its adoption. Studies included in this paper highlight that limited time and restricted access to resources are critical factors that hinder physiotherapists’ ability to engage with research and integrate evidence into clinical practice. The time constraint not only limits physiotherapists’ capacity to stay updated with current research but also affects their application of evidence-based methods, a challenge noted in various studies beyond Sub-Saharan Africa [5] [18] - [21] , as well as across multiple healthcare disciplines [22] - [27] . Furthermore, research indicates that the issue of “lack of time” often encompasses deeper underlying problems, such as insufficient emphasis on learning EBP principles and a reluctance to modify clinical practices or adopt new evidence [28] [29] . Paci et al. (2021) assert that time should ideally be considered a barrier only when practitioners possess the requisite skills and have access to research resources; however, this is frequently not the case in practice. [29] . At the practitioner level, the challenge of managing time is often exacerbated by additional factors such as increased workloads, staffing shortages, and competing responsibilities, which limit opportunities for professional development. Recent research conducted in Bahir Dar in Ethiopia emphasises the critical importance of time management in healthcare settings. The study advocates for the implementation of strategies aimed at enhancing time management skills, including training on effective planning, minimising time-wasting activities, and identifying common habits that contribute to inefficiency, such as procrastination and excessive use of social media. These strategies are essential for mitigating workplace challenges and improving overall productivity [30] . The barrier of limited resources significantly impacts the implementation of EBP among healthcare practitioners. Scurlock-Evans et al. (2014) identified a limited number of investigations focused on the effectiveness of interventions designed to enhance EBP in healthcare settings. These interventions included a psychosocial management approach that utilised opinion leaders, a multi-faceted strategy involving knowledge brokers—individuals who facilitate collaboration between researchers and decision-makers—a formative evaluation project featuring an EBP workshop, a journal club, and a presentation initiative aimed at showcasing local EBP examples The interventions involving knowledge brokers, journal clubs, and local EBP presentations demonstrated increased effectiveness, leading to enhanced familiarity with evidence-supported tools, improvements in EBP practices, and positive shifts in attitudes and intentions to update clinical practices [5] . Organisations can mandate that physiotherapists allocate specific times within their schedules for these activities to further promote engagement with EBP.

The disparities in resource availability highlight the urgent need for organisational support to ensure that physiotherapists have access to essential materials and resources that facilitate effective EBP. Stander et al. (2020) [17] reported that participants perceived a lack of financial rewards associated with CPG uptake, which diminishes motivation to engage with these guidelines. Additionally, Quartey and Kwakye (2019) [11] found that rural organisations are more likely to offer resources such as paper journals, internet access, and personnel to support EBP than urban organisations. Their study also indicated that physiotherapists in teaching institutions receive financial support five times more often than those in non-teaching facilities, suggesting that educational settings offer greater resources for promoting EBP. A study conducted in Malaysia reported that even though journal articles may now be accessed online through a number of databases, some of them need to be paid for or require membership [31] . Organisations that fail to invest in necessary resources may find it difficult to retain talent, as employees are likely to seek environments where they have the tools needed for success and these needs should be communicated to external stakeholders [32] . Furthermore, without proper resources, organisations may struggle with poor service delivery, which can damage their reputation and viability. However, both the practitioner and the organisation must invest efforts in ensuring access to essential resources, such as online information, because the effectiveness of healthcare delivery is reliant on the availability of accurate and timely data.

Three studies highlighted inadequate training and insufficient knowledge and understanding of EBP, particularly regarding statistical analysis and research skills. This lack of training mirrors the findings of a Ghanaian study, which calls for more research to bridge the gap in utilising research findings among physiotherapists. The authors reported that simply distributing health information consensuses through mail or journals does little to enhance clinical practice. They also argued that continuing education activities have minimal impact on the performance of healthcare professionals, as they tend to promote passive acquisition of knowledge. The study noted that the effectiveness of such educational initiatives is limited, as they do not sufficiently motivate physiotherapists to integrate EBP into their daily practice [33] . Research findings underscore the significant impact of peer-to-peer learning and mentorship on enhancing EBP. However, clinicians in regional and rural areas often face limited access to mentorship opportunities compared to their counterparts in metropolitan regions [34] . To improve mentorship access in rural areas, organisations could form partnerships with local entities and leverage technology for remote mentoring opportunities, ensuring that all clinicians benefit from robust support networks. Given that barriers are often context-specific, implementation strategies should be tailored to address particular challenges, emphasising the need to identify specific barriers present in different settings [35] .

Moreover, Maigeh (2003) [36] and Baatiema et al. (2017) [37] revealed persistent barriers to evidence-based practice in healthcare, particularly among physiotherapists in Tanzania and stroke care professionals in Ghana, respectively. Maigeh (2003) highlighted significant obstacles such as heavy clinical workloads, inadequate remuneration, and systemic issues like the lack of policy monitoring and established practice standards [36] . Baatiema et al. (2017) pointed out patient-level barriers, including cultural beliefs framing stroke as divine punishment, late arrival at the hospital, discharge against advice and denial of their condition, and hospital-level challenges like insufficient staffing and resources. Additionally, healthcare provider factors such as inadequate knowledge and poor collaboration further complicate the implementation of EBP in acute stroke care [37] . Addressing these barriers through organisational support, training programs, and community engagement could significantly improve the integration of EBP into routine clinical practice.

While certain barriers, such as time constraints and increased workloads, are prevalent globally, the unique challenges faced by physiotherapists in SSA necessitate tailored interventions. These challenges include addressing cultural sensitivities that may differ significantly from those encountered in nations with differing cultural backgrounds outside the African region. The cultural context can profoundly influence the acceptance and implementation of EBP; thus, healthcare providers must navigate these sensitivities to foster effective practice. Finding a balance between culturally competent practice and the selection of scientifically robust interventions presents a significant challenge when working with ethnocultural groups (ECGs). This balance can be effectively achieved through the application of cultural adaptation procedures [38] . Examples of cultural adaptation procedures could be providing therapist training in cultural competency, flexible scheduling to accommodate cultural norms, using culturally appropriate communication methods and collaborating with community leaders.

The effective integration of research findings into clinical practice remains a significant challenge within healthcare, particularly when clinically relevant evidence is lacking. Research has demonstrated that the absence of clinically relevant evidence presents substantial barriers to the application of research in practice. This issue frequently arises when researchers focus on problems that are not directly relevant to clinicians or propose treatments that are impractical for implementation in real-world settings. The disconnect between the information clinicians require for their daily practice and the evidence provided by research has led to a widespread policy initiative advocating for the co-production of research. [34] . It is, therefore, essential to foster collaboration between researchers and clinicians from the outset of research projects, ensuring that studies prioritise practical and implementable solutions. Furthermore, investing in training programmes that equip clinicians with the skills to interpret and utilise research effectively will help bridge the gap between evidence and practice in this context. Future research should also explore context-specific strategies that can effectively close the divide between evidence and clinical application.

Practitioner facilitators of EBP were also noted, including positive attitudes, knowledge acquired through undergraduate training, engagement with research literature, and a desire for further learning. For instance, Tadyanemhandu et al. (2016) [15] reported that positive attitudes, knowledge obtained through undergraduate training, and reading journals were significant facilitators at the practitioner level among physiotherapists in Zimbabwe. In Nigeria, Ibikunle et al. (2021) [12] noted that positive attitudes and beliefs, confidence in implementing EBP, formal training about EBP, and interest in acquiring new skills were significant at the practitioner level, further emphasising the importance of educational background and supportive attitudes in facilitating evidence-based practice among healthcare professionals. Evidence-based practice has been defined as the integration of personal clinical expertise with the most current and reliable research findings alongside a consideration of patients’ preferences and needs. Central to EBP are two main characteristics: confidence and the judicious use of the best available evidence [38] . A positive attitude further enhances these traits, encouraging practitioners to actively engage with current research and apply it effectively in practice.

Stander et al. (2020) [17] noted that training was a significant facilitator for CPG uptake. Research indicates that there is no uniform approach to educating physiotherapists or assessing the effectiveness of knowledge translation regarding evidence-based practice or clinical practice guidelines outcomes. Recognising local barriers to the utilisation of evidence-based practice or clinical practice guidelines could help tailor the training programme for the specific physiotherapy group [39] . This is consistent with findings from a study conducted in the Philippines, where positive attitudes and self-efficacy were found to be significant factors in the uptake of research evidence among physiotherapists. However, without addressing the identified barriers, the potential for these facilitators to enhance EBP remains limited [40] . Studies by Quartey & Kwakye (2018) [11] and Ibikunle et al. (2021) [12] indicate that advanced degrees in physiotherapy serve as a facilitator for EBP implementation. Similarly, Al Ketbi et al. (2021) [41] found that higher educational qualifications correlate with a greater likelihood of engaging in evidence-based practices among physiotherapists in the United Arab Emirates.

In addition to educational attainment and targeted training programs, organisational support can significantly enhance the uptake of EBP, according to Scurlock-Evans et al. (2014) [5] . These elements, when combined with a supportive organisational culture, create an environment conducive to the effective implementation of evidence-based practices. Furthermore, as highlighted by Sawadogo et al. (2024) [14] , the presence of collective support from colleagues, mandatory use of standardised outcome measures and managerial backing can further bolster EBP adoption. These findings align with findings from Obembe et al. (2019) [42] , which similarly highlighted that organisational support and a culture promoting the use of standardised outcome measures facilitate balanced clinical assessments. However, it is crucial to address the barriers posed by insufficient resources, particularly in resource-limited settings like sub-Saharan Africa (SSA) which may hinder access to these resources.

Ibikunle et al. (2021) [12] , indicated having interest in acquiring more knowledge as a facilitator for EBP. Factors associated with information-seeking behaviours in physiotherapy include affiliation with a professional association. The implications of such membership may suggest that the advantages it offers, such as access to academic journals, encourage members to engage with the research literature more actively. Alternatively, it could indicate that being part of a professional body correlates with a greater propensity to participate in EBP activities [43] .

Addressing contextual factors is crucial for effectively promoting EBP and ensuring that practitioners in resource-limited regions can provide evidence-based care to their patients. Targeted strategies such as developing local networks and integrating EBP during clinical education may harness the facilitators identified in this scoping review. Additionally, the involvement of professional associations and regulatory bodies in advocating for EBP and providing resources and support to practitioners could significantly contribute to its adoption [44] .

It is noteworthy that other studies have not reported organisational facilitators, likely because these aspects were not the primary focus of their investigations. This observation highlights a gap in the literature, as many studies tend to concentrate predominantly on barriers to EBP rather than exploring the facilitators that could mitigate these challenges.

In addition to this, while intra organisational barriers and facilitators have been documented, there is a notable lack of research specifically addressing extra organisational barriers or facilitators that affect physiotherapists in SSA. This gap is significant, as highlighted by Kanmounye et al. (2020) [45] , who identified a lack of mentorship, a lack of institutional review board (IRB) meetings and high costs of IRB approval as significant extra organisational barriers impacting healthcare practitioners. Furthermore, the essay underscores the importance of collaboration with international partners, which can serve as both a facilitator and a barrier. While such partnerships may provide essential resources and expertise, they can also lead to misalignment of research priorities and methodologies that do not adequately reflect local contexts.

The scarcity of research in this area suggests a pressing need for future studies to explore these factors, as they may significantly influence the engagement of physiotherapists in EBP within sub-Saharan Africa.