Knowledge translation in rehabilitation settings in low, lower-middle and upper-middle-income countries: a scoping review

Abstract Purpose This review aims to identify the barriers and facilitators to knowledge use and Knowledge Translation (KT) strategies in rehabilitation in low, lower-middle, and upper-middle-income countries (LMICs). Materials and methods A scoping review of studies of KT in rehabilitation in LMICs contexts using the Arksey and O’Malley Framework was conducted. A comprehensive search of MEDLINE and 10 other databases was undertaken to identify studies conducted primarily in LMICs. Results From the initial 15.606 titles identified; 27 articles were included for final analysis. Our analysis identified the following themes: Professional culture and context; KT interventions; and the conceptualization and application of KT and Evidence Based Practice (EBP). Individual-level barriers to KT included lack of skills, knowledge about EBP and English language, lack of motivation, and decision-making power. Facilitators to KT included positive attitudes and motivation. Organization-level barriers included lack of time, lack of financial resources, limited access to scientific journals, and applicability of research to rural settings. Facilitators included adequate financial and physical resources, a supportive management environment, and the existence of training and continuing education programs. Conclusion This review identified common and unique barriers and facilitators to KT in LMICs when compared to KT studies conducted in high-income settings. IMPLICATIONS FOR REHABILITATION Knowledge Translation from academic institutions to rehabilitation clinical practice in low and upper-middle-income countries is important to support evidence-based practice and patient outcomes. Barriers at the individual level include professionals' ability to understand English and knowledge of the evidence-based practice. Organization-level barriers included lack of time to access and implement new practices, lack of financial and personal resources, limited access to scientific journals, and applicability of research to rural settings. Training and continuing education programs are needed to support rehabilitation professionals' efforts to achieve the application of evidence-based practice in clinical practice.


Introduction
According to the World Health Organization (WHO), the need for rehabilitation services will increase over the next decades due to ongoing demographic, epidemiological, and nutritional transitions, especially in low, lower-middle, and upper-middle-income countries (LMICs) [1]. Rehabilitation, defined by the WHO as "a set of interventions designed to optimize functioning and reduce disability in individuals with health conditions in interaction with their environment" [2] has application across disease and impairment categories [3,4]. It is anticipated that future populations will experience more limitations in functioning and live longer with these limitations [5]. Because of this, there is an urgent need for rehabilitation models of care based on the best available evidence, what is often called as Evidence-Based Practice (EBP), to be strengthened in countries around the world [1].
Knowledge Translation (KT) may be defined as a dynamic and iterative process involving professionals and patients in the synthesis, dissemination, exchange, and ethical application of knowledge to improve health through the development of tools, guides, practical recommendations, and decision-making algorithms [6]. KT strategies are the practices used to support the application of EBP, the creation or modification of health services so that they are better aligned with research evidence and bestpractice recommendations. In these instances, KT may also be a pivotal process to reduce research-practice gaps and address global health inequalities [6,7]. It is known that targeted KT strategies can improve the implementation of EBP, but most evidence in this field has been generated in high-income countries [8,9]. Given the potential benefit of KT strategies to improve EBP in rehabilitation and ultimately, patient outcomes in LMICs, there is a need to identify what strategies have been used, and under what circumstances, to make relevant evidence available and accessible in clinical practice.
Evidence generated through rigorous scientific methods is an integral source of knowledge for both policy and practice in the health disciplines, including rehabilitation [10][11][12]. Persistent discrepancies exist between the research evidence, its dissemination, and its eventual use to inform population health, clinical practice, and decision-making at various levels [13][14][15]. According to Barac et al., most evidence-based treatments that have been established are difficult to implement in real-world contexts, due in large part to structural barriers [16]. Barriers, such as lack of time for professionals, difficulty in accessing relevant databases, high cost of continuing education and participation in scientific events, and journal subscription fees all characterize many practice settings. Health professionals also face individual barriers to implement EBP in their practice context. Practitioners report difficulties in reading articles and selecting the most relevant information, especially because most peer-reviewed research is published in English internationally [17,18]. In addition to practical barriers to information access and use, there is growing recognition that not all evidence is directly applicable to local contexts and the evidence itself is situated within implicit paradigms that may be disconnected from local ways of viewing health and illness [19,20]. Knowledge Translation interventions that are sensitive to these considerations can help address many of these barriers to EBP.
Health care services may face unique challenges in LMICs for several reasons, including socio-economic and political factors, lack of relevant evidence, and adaptation of scientific evidence generated in High-Income Countries (HICs) [21,22]. Examples of KT studies done in upper-middle-income countries, such as Brazil, show that about 60% of health professionals working with children reported difficulties in assessing specific aspects of children's development due to the absence of EBP guidance on the management of specific disorders [23]. There is a need to learn from studies conducted in these settings, to better understand the common and unique barriers and facilitators, strategies, and perspectives on knowledge [24].
Social, economic, and environmental discrepancies between LMICs mean that EBP studies carried out in High-Income Countries (HICs) may not be readily transferable. Possible reasons for the poor transferability of evidence-based information include barriers related to differences in the organization and norms of rehabilitation services and the culture of care and resource capabilities that are critical to the success of knowledge generation, adaptation, and implementation [21,25]. It also includes the users' context, the presence (or lack) of an enabling environment, and the perceived relevance and the type of evidence being transferred [21,26]. The gap between evidence generation and application may be particularly critical in rehabilitation services where there is a high demand and low availability of services [27]. To identify the key barriers to knowledge uptake from scientific research into clinical practice in these countries is therefore critical to enhance healthcare policy and services [28].
In this scoping review, we identified KT studies in rehabilitation in LMICs outlining the barriers and facilitators to evidence-based practice and the extent of the use of KT strategies in rehabilitation in these settings.

Methods
We conducted a scoping review to map KT studies in rehabilitation in LMICs [29,30]. We used Arksey and O'Malley's [29] five-step framework to guide this review.

Step 1: identifying the research question
The primary question that guided this review was: What are the most common barriers and facilitators to knowledge translation (to promote the uptake of evidence-based practices) among rehabilitation practitioners (physical therapists, occupational therapists, speech and language therapists, kinesiologists) in LMICs? The second question was: How is KT conceptualized and applied in LMICs? In this context, we define KT strategies as those addressing research-practice gaps and improving health care practices through targeted actions. To identify the different types of KT strategies, we used the Cochrane Effective Practice and Organizational Change (EPOC) taxonomy [31]. The EPOC taxonomy of health systems interventions classifies interventions according to delivery, financial, and governance arrangements and implementation strategies. The taxonomy has been developed to be relevant to low-income countries and helps structure the analysis of KT interventions identified in this review.
We limited the scope of rehabilitation to the professions listed above as we agreed as a team that the professional practice for these professions is unique and commonly classified in these countries as rehabilitation professionals, different from other healthcare professionals, such as nurse practitioners and physicians who may be involved in rehabilitation but are not particularly known as rehabilitation professionals.
Step 2: identifying relevant studies A health sciences librarian developed the search strategy and performed the literature searches in MEDLINE (Ovid), EMBASE (Ovid), PsycInfo (Ovid), Global Health and Global Health Archive (Ovid), CINAHL, Cochrane Central, ERIC (ProQuest), PAIS Index (ProQuest), Proquest Dissertations and Theses, Scopus, and WHO Global Index Medicus (includes LILACS) from database inception started on 3 April 2019 until 7 July 2021, with no limits or language restrictions. The MEDLINE strategy was developed with input from the project team, and peer-reviewed by a second librarian using the PRESS standard [32]. After the initial MEDLINE strategy was finalized, it was adapted for use in the other databases. The search strategy (see Supplemental material) was designed to identify all relevant literature on the concepts of knowledge translation, rehabilitation (defined as physical therapy, occupational therapy, speech-language pathology, kinesiology, and multidisciplinary teams with these professions) in low, lower-middle, and uppermiddle-income countries using the 2012 filter by the Norwegian Satellite of the Cochrane Effective Practice and Organisation of Care Group, that are filters based on the World Bank list of countries (2019), classified as low-income, lower-middle-income or upper-middle-income economies [33]. This filter is used for PubMed (NLM), MEDLINE (Ovid), Embase (Ovid), and CENTRAL (Cochrane Library) to help identify studies relevant to LMIC [34].
Results from each database were exported into EndNote and duplicates were removed.
Step 3: study selection Inclusion criteria were: (1) studies published between 2006 and 2021. The publication date restrictions reflect the developing interest in KT since the 1990s and the exponential growth in publications on KT after 2006, following the publication of Graham's seminal paper defining KT as a term [35]; (2) include rehabilitation practitioners (physical therapist, occupational therapist, speech therapist, kinesiologist) as study participants, (3) be written in English, French, Portuguese, Spanish, or Hindi; and (4) conducted primarily in low, lower-middle and upper-middle-income countries according to the World Bank classification [36] (5) any study design and methodology. Exclusion criteria were: (1) the target audience was MDs/physicians, social work, nursing practitioners, and (2) the primary study site was not a low, lower-middle, or upper-middle-income country. In addition, dissertations, conference abstracts, editorials, books, and book chapters were excluded due to limited time and resources. In the case of study protocols, a hand-search for a publication of their results was performed and included if retrieved; otherwise, protocols alone were excluded. Evidence syntheses (e.g., systematic reviews) were excluded to avoid duplicate representation of studies.
Citations were imported and managed using Endnote X7.7.1 and then transferred to Rayyan (https://rayyan.qcri.org/) for study selection and data extraction. The study selection process consisted of three parts: (1) duplicates were removed by the librarian; (2) calibration for selection criteria amongst the research team (IR, EG, AL, RC, RL): Using a priori screening criteria, a random sample of 10% of the total number of articles retained was screened (titles and abstracts). Agreement of <90% was obtained in the first 10% of studies, so the criteria were refined in discussion with an additional team member (KS), and applied again by all reviewers to an additional 10% of random titles and abstracts. With this second round, an agreement of more than 90% was obtained among authors, then reviewers were divided into pairs (IR and RC) and (EL and RL) to independently review tittles and abstracts; (3) the same pairs assessed the full-texts for eligibility and inclusion into Step 4. Disagreements were resolved by two additional reviewers (KS and RL). The entire team met regularly to discuss disagreements and preliminary findings and review decisions.
Step 4: data extraction and charting A data extraction form was created to collect the following data: author, year of publication, country of origin, funder, study design, knowledge user (who is likely to be able to use research results to make informed decisions about health policies, programs, and/or practices [6]), years of work, setting, engagement characteristics and contextual factors (e.g., country income level, implementation problem, use of a framework to inform the intervention), clinical intervention (frequency, KT delivery, KT providers, KT strategy, KT session length) barriers and facilitators to engagement (organizational and individual), and results of any formal assessment of engagement (e.g., attitudes, beliefs, knowledge, benefits, unintended consequences).
Five team members reviewed a random sample of 10% of the articles to abstract data into the data extraction sheet. The team met to discuss the extracted data and identify if there were any conflicts in the data extracted to each cell. A data extraction guide was created to describe the information that should be added to each cell, and all team members applied the same criteria and worked independently to extract the data. Regular team meetings were held to refine the extraction sheet (e.g., improve the data extraction definitions) and resolve any disagreements on the data extracted.
We did not conduct a critical appraisal of the articles as it is not a requirement of the scoping review methodology and we expected a heterogenous sample of methodological approaches, designs, and outcome measurements. Discrepancies were resolved through discussion.
Step 5: collating, summarizing, and reporting the findings We conducted a descriptive and thematic analysis of the data. We first described the nature and distribution of the studies; context, barriers and facilitators, nature of dissemination and implementation used in developing countries; and strategies used.
To collate, summarize, and report the results we adopted a thematic content analysis approach. Each column in the data extraction sheet served as a data point for analysis. For instance, all the content compiled in the "contextual factors" column was summarized and considered one data point [29]. Each data point was analyzed thematically. The thematic content analysis of each data point served to address the overarching question of the barriers and facilitators for KT to support EBP for rehabilitation and to outline the KT strategies used in rehabilitation practice in these countries as presented in the articles under review. Two members of the research team independently reviewed the summarized data and identified preliminary themes. All other members of the research team were then consulted to discuss the preliminary themes and potential other concepts to develop from the data. Then two members of the team continued the analysis and summarized the results, in an iterative process among the entire research team. A summary of the major findings organized by themes is presented below.

Literature search
A total of 15 606 titles were identified, and 11 646 citations remained after duplicates were removed. From the 114 abstracts eligible for full-text review, 27 articles were included in the final analysis: 23 studies assessed barriers to knowledge use, and four presented KT interventions. See Figure 1 for an overview of the search process.

Characteristics of articles and reported studies
Out of the 27 articles retained for the review, 88.9% were published after 2010. Twenty-two (81.5%) studies described Physiotherapist practices, primarily of professionals between the age of 20-30 years (48.1%), with <5 years of clinical practice. The majority of studies (66.7%) were conducted in large rehabilitation centers located in urban centers and serving large and heterogeneous clienteles. Table 1 provides more details on the characteristics of the "end users" involved in the studies reviewed.

Thematic analysis
Through a thematic analysis of the collected articles, the team identified three key themes relating to rehabilitation professionals and KT practices in LMICs: Professional culture and context (individual and organizational barriers and facilitators); Effectiveness of KT interventions; and the conceptualization and application of KT to EBP.

Professional culture and context
Studies assessed barriers and facilitators related to professional culture in LMIC (see Table 3 for a list of barriers and facilitators identified across studies and Table 4 for specific details of context and practice described in each study reviewed).

Individual barriers and facilitators.
Examples of specific contextual barriers attributed to the individual level included aspects the limited duration (i.e., 2 years or less) of professional training programs for physical therapists in some countries [57][58][59], the lack of opportunities for engagement in continuing education, and absence of regulations mandating continuing education for professional practice [47,48,52,53,[58][59][60]. Possible solutions suggested to address such barriers included teacher training and continuing education courses offered by non-governmental organizations, or educational institutions [52,56]; however, these solutions were not tested and details of how these could be delivered in settings where other contextual barriers exist (e.g., funding, health, and education systems-barriers), were not presented in most cases.
Some systems-related issues were considered individual barriers to KT for EBP. These included the lack of professional skills to use standardized assessment tools [42,43,[46][47][48][49]58,60,61]. The language in which the research evidence is made available was frequently mentioned as a barrier to KT [   language understanding served as a barrier for health professionals. They also found a lack of motivation to search scientific literature related to the clinical practice and decision making-process as a key barrier to EBP implementation, although the concept of "motivation" was not interrogated further (e.g., to examine the relationship between motivation and systemic issues, such as access to language-appropriate resources). The scarcity of studies about the adaptation of EBP strategies for clinical practice research in these types of contexts and settings also presented as a systems issue being an individual barrier to the use of research to inform practice [42,58]. While few facilitators for KT were mentioned in most studies, three articles cited positive attitude and motivation as factors supporting KT [37,42,45,47,49,56,59]. Two others reported that professionals' strong foundational knowledge of the clients' conditions and strong clinical reasoning skills contribute to KT, as well as a knowledge-seeking behavior [39,53].
Organizational barriers and facilitators. Common organizational barriers related to the professional context and culture describe the lack of adequate time to handle a high volume of patients not allowing for more opportunities to engage in EBP recommendations [37,38,[40][41][42]46,48,49,[52][53][54]56,58,[62][63][64]. The lack of adequate financial resources in different services settings also limits the organizations' capacity to promote KT strategies [41,46,48,52,[56][57][58] and is also related to aspects, such as the limited access to scientific literature either because of language restrictions or funds to make scientific databases available in the clinical practice setting [41,42,[62][63][64], overall low organizational support [53], and lack of evidence-based information adapted to the specific context [39,41,42].
The organization of services was also cited as a barrier to KT, where professionals are responding to a high volume of patients and need to take on diverse professional roles, which may impede them from accessing and using research into practice [37][38][39][40]54,57,58].
The macro structure of health policies and regulations that do not favor the use of EBP implementation was a frequently cited barrier to KT efforts. This included legal disputes involving the scope of professional practice and professional regulations for physiotherapists. In these cases, it was perceived that the important resources (time and energy) and the attention of professional regulation bodies and services managers were spent on legal disputes and professional management, limiting their ability to promote EBP [38,40,54]. The micro-structure of non-supportive managers or administrators within rehabilitation services was also perceived as an important barrier to KT [38,40,42,58].
Access to scientific publications was also cited as a common barrier to KT [49,59,[62][63][64]. However, when access was made possible, studies showed that the evidence was frequently perceived as not applicable to the context of practice. For instance, the application of knowledge that was generated in large rehabilitation centers located in urban settings was not applicable to small, often isolated rural area practices. Patient-centered care in the context of poverty or extreme social-material deprivation, or when aspects, such as basic needs are not met, or literacy is low also did not have the same bearings as patient-centered care in higher-income settings [53,58].
Buchanan et al. [56] identified the lack of time for holding workshops during the process of implementing EBP as an organizational barrier specific to the context of practice in resourcestrained rehabilitation settings.
Some barriers identified were specific to the context of some countries, such as the disruptive impact of civil conflict in Afghanistan [57] and the subsequent suspension of health care providers' training programs, or the geographic distance that would need to be covered for professionals working in rural settings in India to access continuing education courses [53].
Other barriers included the positioning of rehabilitation professionals in the health care system. For example, in the Philippines, some health professionals, such as physiotherapists cannot deliver EBP: evidence-based practice; RTC: randomized controlled trial. EBP: evidence-based practice. Positive and favorable attitudes and post-graduation.
Kaunnil [60] Thailand To explore perspectives and experiences with occupationbased practice among Thai occupational therapists. Currently, Thai universities embrace a model of outcomebased education and educational theory to help learners to meet learning outcomes. The occupational therapy programme was impacted by the policy and determined to be one of the curricula assessed by the AUN-QA. The key objective of the AUN-QA process is to create anticipated learning outcomes, in which OBP was established as part of the essential knowledge and abilities that students should possess after programme completion. Hence, it will be a major change in the future Thai occupational therapy community as this initiative grows.
Cultural influences and social values impact care and support; environmental resources and hospital policy Teamwork; work skills, competence, and capacity to continue working.
Ibikunle [40] Nigeria To investigate the barriers physiotherapists in Nigeria encounter in implementing EBP in stroke management.
Physiotherapy, as a key component of stroke rehabilitation, needs to incorporate EBP in its stroke care to forestall sub-optimal patients' treatment outcomes that may negatively affect the patient's ability to reintegrate into the community and lead to dissatisfaction on the part of the patient and the physiotherapist. However, despite the recent advances and the large body of existing knowledge, uptake of EBP in clinical settings remains slow especially in lowand middle-income countries, suggesting that only a small proportion of stroke patients receive optimal care and the majority, suboptimal.
Insufficient time, lack of information resources, lack of organizational mandate. Lack of research skills, Education on EBP, higher academic degree, less daily workload, more years of experience, more participation time in research and teaching, and belonging to a professional association.
Nascimento [41] Brazil To identify the personal and organizational characteristics associated with the use of evidence-based practice by physical therapists providing services to people with stroke in Brazil. Although the evidence-based practice has been widely used by physical therapists, data variation suggests that its implementation may be influenced by several factors. Population-specific information is required to help enhance the use of research in clinical practice. Dao [48] Viet Nam This study explores whether Vietnamese physical therapists' attitude, knowledge, skills toward EBP, and barriers to its use make them ready to implement its practice. Physical therapy practice is based on physician prescriptions and PTs decide specific methods to apply on their patients, which may or may not be optimal for patients' conditions. The need to improve patient outcomes is necessary. Time.
Positive attitude towards EBP.
Jadhav [51] India To explore PA's knowledge, attitude, and practice in India's routine physiotherapy practice. Physiotherapist plays a crucial role in PA promotion, but lack of updated knowledge leads to lesser and inefficient promotion in their clinical practice.
Lack of resources; do not find it beneficial; lack of time Lack of counselling skills; lack of motivation.
Aweto et al. [37] Nigeria To determine the knowledge, attitude, and practice of Nigerian physiotherapists towards the promotion of non-treatment physical activity among patients. Physiotherapists have great potential for physical activity promotion. They prescribe exercises for a wide range of conditions (mostly musculoskeletal) requiring rehabilitation.
Insufficient consultation time.
Good knowledge and good attitudes.
(continued) services or treatment to patients without a medical prescription [52]. And because of this, even if they know what the evidence supports, they couldn't necessarily implement it because they must follow the prescribed treatment.
Fifteen studies [39][40][41]45,47,49,52,53,[58][59][60][62][63][64] identified organizational facilitators of KT. Among them were contexts where there were adequate resources, including materials, space, and financial support; a well-equipped library; participation of public health administrators; and an environment of support and encouragement for change. Seven articles also listed training and continuing education programs as facilitators of implementation in low, lower-middle, and upper-middle-income countries [40,47,52,53,59,60]. Therapists providing services in rural regions often do not have access to continuing education and mentoring that can promote EBP [58].

Effectiveness of KT interventions
Only four studies reported on the evaluation of KT interventions [52,55,56]. The studies incorporated an educational aspect and focused on the implementation of EBP. All three studies implemented a multifaceted intervention including emails and face-to-face training, lectures, and practical workshops. The KT interventions are summarized in Table 5. We describe the studies in more depth in the remainder of this section.
Frieg et al. [55], carried out a workshop addressing EBP for physiotherapists in South Africa focusing on physiotherapy clinical facilitators. The workshop was evaluated using three questionnaires developed by the authors. The first questionnaire consisted of background in clinical supervision and their expectations of the workshop; the second questionnaire was completed on the last day of the workshop; the third was carried out three months later by mail to all the participants. After three months, the participants indicated that having discussed topics about knowledge, skills, and attitudes for clinic education had a positive impact on their practice. Most professionals felt that they were much clearer about their roles and knew more about their own learning styles following the workshop. This was the only study included in this review that carried out an evaluation of participants' expectations, and the perceived impact of the KT strategies on EBP implementation.
An RCT by Dizon et al. [52] tested KT interventions to improve EBP for physiotherapists in Philippines. They compared the intervention group with a control group to identify the changes in behavior and attitudes after the lectures and practical lessons. The professionals were evaluated pre, post, and three months after the intervention. Pre-post intervention measures of knowledge and skills associated with EBP were assessed using structured questionnaires and diaries to register behavior information. In the post-training assessments, the EBP group was significantly more confident in undertaking literature searches and critical appraisals. These differences were sustained at three months.
Another RCT by Buchanan et al. [56] compared two types of training, The Interactive Educational intervention (IE) and The Didactic Educational intervention (DE) with occupational therapists in South Africa. Within-group analyses showed significant increases in knowledge in both groups but no significant differences in attitudes or behaviour. There were no significant differences on any of the attitude subscale scores or any other significant differences between groups. The authors concluded that the lack of significant attitudes changes between the groups could reflect the poor reliability of the attitude sub-scales in the instrument used, or indicate that the professionals had such low levels of   The professionals planned to further study the ICF-CY framework and to share with different individuals the new tools to which they had been exposed PCSs have the potential to be a more effective measure of CPD outcomes for health professions in LMICs.
PCSs guide health practitioners to reflect on the implementation of change to their knowledge, skills, or performance in practice.
Structuring PCSs may guide reflection on both the direction and process of change including anticipated barriers and measures of success.
Dizon et al. [53] (1) Estimate the effect size of the  knowledge that any intervention would improve the readiness to change. Unlike the other articles cited, Bornman et al. [65] explored a case study conducted at a 1-day interprofessional continuing professional development (CPD) event held for health practitioners in South Africa. A qualitative thematic analysis was made of Personal Commitment (to change) Statements (PCSs) evaluation, and results were synthesized into main themes. Thirty-two participants turned in a PCS at the end of the CPD event with a total of 71 text statements. Three main domains were identified: applying new knowledge in practice, increasing training-related content knowledge, and sharing information, skill, and resources. The results demonstrated that personal commitment statements can be used to describe the outcomes of CPD events for audiologists, speech-language, occupational, and physiotherapists. Participants engaged in reflection generated by the personal commitment statement, showing that participants were more aware of the assessment tools and how they could use them in practice.
Professionals' readiness to change was used as an outcome in all four intervention studies. Importantly the studies did not describe the specific characteristics of the interventions (i.e., duration, timing, delivery methods) associated with variations in readiness to change across studies (see Table 5 for more details).

The conceptualization and application of KT and EBP
We explored how authors conceptualized KT and EBP in the included studies. The studies acknowledged that changes in clinical practice and implementing strategies based on EBP knowledge are necessary, but few reported effective KT strategies through which these changes could occur [37,38,[40][41][42][52][53][54][55][56]62].
KT was often conceptualized as attitudes and behaviors towards EBP, such as (1) articulating questions that arise from clinical practice in a searchable format; (2) effectively finding the best evidence to address the question (which may require an online literature search); (3) critically appraising the evidence for validity; and (4) evaluating the impact and applicability to the clinical question [38,40,41,54].
Several EBP protocols were reported in different countries, each with the aim to facilitate the dissemination and implementation of EBP including (1) The Evidence-Informed Practice (EIP) [53], (2) Advanced Physiotherapy Practice (APP) [54], (3) Programme Rehabilitation of Afghans with Disability (RAD) [58]; Clinical practice guidelines (CPGs) [66]; and (4) Continuing Professional Development (CPD) [38] the first three of which are models of health care delivery created, respectively in India, Ghana, and Afghanistan. These studies reported included educational meetings and printed educational materials (based on EPOC taxonomy) [31] as the main KT strategies. KT intervention components comprised face-to-face training workshops, interactive activities with discussions, role play, and reflexive strategies to facilitate the KT. Providing access to online databases with guidelines, systematic reviews, or pre-appraised literature was considered to be "best practice" in supplementing the active KT interventions.

Discussion
The primary objective of this scoping review was to identify the type of research being conducted on KT and EBP strategies in these LMICs. Our findings indicate that there are few studies of KT interventions in these countries. The included studies highlight organizational and individual barriers to KT in these contexts that are very similar to those identified in the high-income country (HIC) settings. KT studies in HICs consistently describe that barriers to implementing change are related to the structure of day-today practice, routine, culture, values of the organization, availability of resources, such as time, funding as well as negative attitudes of leaders and employers [67,68]. Barriers that may be more specific to the LMICs context are related to the diverse professional roles that rehabilitation professionals assume, the high volume of patients, the language in which scientific evidence is published, limited access to information due to lack of resources, and challenges in adapting research evidence to the local context. These findings provide important context to considerations of the transferability of findings and strategies across settings.
Some known barriers encountered in implementing EBP in LMICs can be addressed using effective KT strategies. Changes in the transmission and use of knowledge are only possible when perceptions, attitudes, and beliefs are taken into account [37,38,40,54]. In Latin American countries, a study suggests that language is an important obstacle to professionals' uptake of the latest research evidence [46,49,50]. The lack of translation and culturally adapted information of scientific evidence into languages other than English makes it difficult to implement the evidence produced to improve clinical practice [71,72]. Language may also impact the possibility of researchers and clinicians to share their own experiences and research more broadly in English academic venues, limiting knowledge sharing. Investing in the translation of existing literature from other languages, and supporting and incentivizing the production of knowledge in the local languages can be effective and transformative [71]. While the issue of language is an important barrier to research uptake, consideration must be given to the context in which evidence is generated, the conditions that may differentiate this context from diverse practice settings, and the structural features of the practice context that may facilitate or hinder the application of best-practices identified in high-resource settings. Our findings suggest that there is a need for further research to examine the ways in which the practice context changes the application of evidence and how to practice context can be integrated as a feature of the research design. Part of this approach requires researchers and practitioners to critically examine the taken-for-granted assumptions embedded in notions of EBP, and to what extent these assumptions create space for different ways of knowing and culturally rooted and relevant processes and outcomes [73]. Tensions in pursuing such an aim are acutely apparent in the scholarly discourse pertaining to the "global mental health" movement. Critics have argued against the generalization and universalization of approaches to diagnosis and clinical intervention that often originate in unique (i.e., western) contexts [74]. They have argued that clinically relevant knowledge must reflect deeply the diversity of illness experiences and acceptable approaches to care [75].
This scoping review revealed the shortage of studies testing the implementation of KT strategies in rehabilitation. EBP in rehabilitation can contribute to the quality of life, performance, and function of populations in low, lower-middle, and upper-middle-income countries [52,55,56]. Combined with health promotion and disease management interventions, rehabilitation is instrumental in comprehensive global health efforts focused on persons with disabilities and chronic health conditions [1]. Only three [52,55,56] KT intervention studies were included in this review, revealing the scarcity of studies implementing and evaluating KT interventions in rehabilitation in low, lower-middle, and uppermiddle-income countries. Descriptions of KT interventions generally lacked details, making it difficult to replicate these studies in other contexts.
In some settings, a lack of professional autonomy may result in the adoption of prescribed interventions by a physician that may not be evidence-based or follow best-practice recommendations, or are simply transplanted from other contexts without consideration of adaptation or applicability. In places where there is very limited access to health care providers, physiotherapists have taken on diverse roles, often beyond the traditional scope of practice regulated in their country, such as education, community health strategies, and counseling [48,54]. The multiple roles can have a positive impact on the establishment of the profession but may compromise KT for EBP when practice spans to diverse roles and specificity are not possible.
Where KT interventions were described, workshops and educational material were the most common strategies used. All intervention studies in this scoping review presented positive outcomes indicating that this strategy, although not seen as the most effective, can improve the propensity for professionals' behavior change [52,55,56,65]. This information is relevant for LMICs, but it is necessary to consider that only three implementation studies were identified. Therefore, the experiences and difficulties mentioned by professionals in these studies may be considered when working with EBP implementation and offer initial data on an important area for further inquiry.
Research on the implementation of EBP in LMICs is more common in areas, such as communicable diseases and primary health care [76][77][78][79][80]. The focus on implementing strategies to decrease mortality and improve survival rates in these countries reflects a common trend of the healthcare system with less emphasis on prevention and rehabilitation of health.
Training and continuing education programs have the potential to be effective means to foster KT and EBP in low, lower-middle, and upper-middle-income countries [47,48,52,55,56,60]. It is also important to educate and raise awareness among health administrators to understand the value of KT and EBP and support the creation of structures and programs that minimize barriers to the implementation of EBPs.

Limitations and implications for future research
Our search strategy used LMICs as inclusion criteria. This emphasis does come with the risk of assuming a uniformity across countries that fall within this category when there is great heterogeneity across countries. This limitation has a methodological component: that we limited our search strategies for research identified as being done in these countries, knowing that this is a somewhat artificial divide. By recognizing this risk, we have attempted to ensure that the contextual features described in the studies are represented in our findings. In other words, we do not assume uniformity and have attended to differences across studies as well as similarities.
Future research can draw upon several important gaps identified by our review. Studies should aim to further characterize the systemic barriers and facilitators for KT implementation in LMICs. The scientific community, clinicians, and healthcare system users should collaborate on implementation studies to develop a better understanding of current realities and create a support network for decision-making and dissemination of the solutions found. Further research should also be directed at examining the broader research infrastructure within a country, namely funding available for local research, the support provided for research institutions, the relationships between research institutions and health care facilities, and how this infrastructure shapes the KT process. There is an emerging recognition that KT strategies should be tailored to the local context where implementation studies should be conceived in collaboration with end-users, and making science generated globally more relevant to improve rehabilitation practices and population health [81,82].

Conclusion
To date, few studies have identified barriers and facilitators toward implementing best practice in rehabilitation, and even fewer have tested the effectiveness of KT strategies in LMICs. Individual professional barriers include a lack of skills, motivation, and language that prevent KT towards EBP from being implemented in these countries. In contrast, professionals' knowledge of their clientele and understanding of the current context or practice, as well as active strategies for continuing professional educational can act as facilitators for the implementation of EBP in these contexts. Important organizational barriers include lack of time, resources, funding, and access to quality scientific articles in the local language. These findings are situated in the finding that more high-quality research needs to be conducted in these countries to better understand the KT process, from knowledge generation to uptake and use.

Disclosure statement
No potential conflict of interest was reported by the author(s).

Funding
This work was carried out with the support of the Coordination for the Improvement of Higher Education Personnel-Brazil (CAPES)-Financing Code 001.