Physiotherapists’ Knowledge, Confidence, Barriers, Enablers, and Perceptions of Strength Exercise Prescription in the Kingdom of Saudi Arabia: A Mixed-Methods Sequential Exploratory Design

Abstract

Background: Strength exercise prescription is an essential component of physiotherapy practice, yet limited evidence exists regarding physiotherapists' knowledge and practices in Saudi Arabia, particularly concerning strength exercise as distinct from general physical activity promotion. Therefore, this thesis aimed to explore Saudi physiotherapists' knowledge, confidence, barriers, enablers, and perceptions of strength exercise prescription to inform educational and clinical initiatives. Methods: A sequential exploratory mixed-methods design was employed comprising three phases: a scoping review examining Saudi and Gulf region healthcare professionals' knowledge, confidence, barriers, enablers and perceptions of physical activity promotion and strength exercise prescription; four online focus groups (n=14) exploring Saudi physiotherapists' experiences in depth; and a cross-sectional national survey (n=124) assessing knowledge accuracy, confidence levels, barriers, enablers, and perceptions. Findings were organised and interpreted through the Capability, Opportunity and Motivation (COM-B) framework. Results: The scoping review revealed limited focus on strength exercise in the Gulf region with knowledge gaps in physical activity promotion. Focus groups identified five themes: gaps and grey areas in strength exercise knowledge; learning through practice; factors supporting prescription; practical challenges; and strength exercise as essential yet questioned in scope. The survey demonstrated variable knowledge accuracy (only 10.48% correctly answered all prescription principles questions) alongside consistently high confidence (83.1%), with no significant associations between knowledge and qualification, years of experience, or work environment. Patient non-adherence (54.1%) and negative beliefs about exercise (53.2%) emerged as primary barriers, whilst positive clinical outcomes (86.3%) were key enablers. Motivation was consistently high, with 89.1% agreeing that all physiotherapists should know how to prescribe strength exercises. Conclusion: Saudi physiotherapists demonstrate great motivation and professional identification with strength exercise prescription but face significant knowledge gaps and uneven opportunities that limit evidence-based practice. Knowledge is acquired primarily through experiential learning rather than formal evidence-based education. This thesis provides the first comprehensive strength exercise-specific exploration of Saudi physiotherapists' competencies and identifies recommendations for enhancing educational curricula, continuing professional development, and healthcare policy.