Cardiorespiratory physiotherapy as a career choice-perspective of students and physiotherapists in Portugal.

We investigated Portuguese physiotherapy students' and physiotherapists' (1) perceptions of cardiorespiratory physiotherapy (CRP); (2) factors that influenced their decision to pursue a career in CRP; and (3) suggestions to develop CRP. Online surveys were disseminated to final year students and physiotherapists. A number of 189 students (mean age 23 [SD 6] years; 78% ♀) and 375 physiotherapists (mean age 31 [SD 8] years; 78% ♀) participated. Students' opinions about CRP were positively influenced by lecturers (n = 112, 69%), clinical experiences (n = 110, 68%), and scientific evidence (n = 93, 57%). Only 13% of students were "extremely interested" in specializing in CRP. Interest in the area and clinical exposure were the main factors influencing students to pursue a career in CRP. A percentage of 15 of responding physiotherapists were working in CRP. Their decision to pursue a CRP career was most influenced by their interest in the area (n = 37, 67%) and opportunity to work in acute settings (n = 31; 56%). Main suggestions to develop CRP were (1) include placements in CRP; (2) emphasize health promotion within the curriculum; and (3) develop CRP skills in broader contexts and training. Strategies focusing on changing the curriculum, increasing exposure to CRP, providing good mentorship, developing health promotion activities, and creating postgraduate courses may increase the attractiveness for CRP.


Introduction
Noncommunicable diseases (NCD), such as cardiovascular diseases, chronic respiratory diseases, diabetes, and cancer, are lifestyle-related diseases currently responsible for 40 million deaths/year, equivalent to 70% of all deaths globally (World Health Organization, 2017). The United Nations and the World Health Organization have targeted a reduction of one-third of premature mortality due to NCD by 2030 and are currently considering the prevention and treatment of these conditions a worldwide priority (World Health Organization, 2017). Cardiorespiratory physiotherapists work in a variety of sectors and settings within the health systems (e.g., hospitals, rehabilitation centers, community health centers, private practice, and academic environments) to improve quality of life and physical fitness, maximize function, educate and promote healthy lifestyles (Australian Physiotherapy Association, 2017). Therefore, these professionals work with a wide range of health conditions that impact on the cardiac, respiratory, vascular, and metabolic systems (Dean et al., 2011(Dean et al., , 2014World Health Organization, 2013), and their effectiveness in preventing and managing NCDs is well established (Dean et al., 2011(Dean et al., , 2014World Confederation for Physical Therapy, 2013;World Health Organization, 2013). Despite the burden of these conditions and the wide scope of cardiorespiratory physiotherapy (CRP) practice, physiotherapy students have been showing more interest in other areas of physiotherapy, such as musculoskeletal or sports (Janaudis-Ferreira et al., 2016;Mulcahy, Jones, Strauss, and Cooper, 2010;Öhman, Solomon, and Finch, 2002;Öhman, Stenlund, and Lars, 2001;Reeve et al., 2012).
The students' lack of interest by the CRP area has been raising concern within international physiotherapy societies (Dean et al., 2014;Limb, 2009), as it may lead to few specialized cardiorespiratory physiotherapists. CRP is one of the main noninvasive and cost-effective practices with a labor pattern consistent with the needs of effective health education delivery and implementation (Dean et al., 2011(Dean et al., , 2014. Thus, having few professionals in this area may affect the prevention and treatment options offered to patients and families with NCD. Nevertheless, few studies have been conducted to comprehensively understand the reasons for choosing or not CRP. Previous studies have shown that the main factors influencing students not to specialize in CRP were their experiences; academic and clinical role models/ mentorships (Janaudis-Ferreira et al., 2016;Reeve et al., 2012;Roskell and Cross, 2003) opportunities for postgraduate studies, employment (Reeve et al., 2012), and perception of low levels of competency (Roskell and Cross, 2003). Nevertheless, representative samples were never included which impairs the generalization of the results found. Additionally, physiotherapists are the fifth largest health profession and the primary noninvasive health profession with primary responsibility in targeting NCD (Dean et al., 2011(Dean et al., , 2014). Yet, the perspectives of these professionals on CRP remain unknown.
Therefore, this study sought to explore Portuguese final year physiotherapy students' and physiotherapists' (1) perceptions of CRP in comparison with other areas of physiotherapists' specialization; (2) factors that influenced their decision to pursue or not a career in CRP; and (3) suggestions to guide the direction of further development of the CRP specialty. By having representative perspectives of students and professionals, we will be improving our current understanding of physiotherapy education and practice and supporting the advance of national and international guidelines for the development and implementation of CRP toward what needs to be modified, why and how.

Study design and ethics
This was a cross-sectional online survey conducted in a joint collaboration between the School of Health Sciences, University of Aveiro, Portugal and the Department of Physical Therapy, University of Toronto, Canada. Ethical approval was obtained from an independent Health Sciences Research Unit Ethical Committee (ref. P223-09/2014).

Participants
Physiotherapy students and physiotherapists were invited to participate. Students were considered eligible if they were final year physiotherapy students, in an attempt to guarantee that they had already experienced patients with cardiorespiratory conditions. Physiotherapists were included if they had a degree in physiotherapy and were working in Portugal. Students and physiotherapists were excluded if they did not digitally consent to participate or closed the questionnaire without submitting the answers.

Recruitment
A modified Dillman's approach was used for the recruitment (Dillman, Smyth, and Christian, 2014). All 18 institutions (public or private) offering undergraduate physiotherapy programs in Portugal and the Portuguese Association of Physiotherapists were contacted. After obtaining the consent from the institutions, detailed information about the study and two LimeSurvey hyperlinks (i.e., one survey directed to physiotherapy students and the other directed to physiotherapists) were sent via e-mail. A request to disseminate the links across the contacts of each person was included in the e-mail. Institutions were asked to disseminate the study and surveys by their students and professional contacts (e.g., lectures, clinical mentors/ supervisors, and services). Two follow-up e-mails were sent 2 and 3 months after the initial contact, acknowledging students and physiotherapists for completing the questionnaire or reminding them to do so.

Sample size calculation
A sample size calculation for surveys, based on Bartlett, Kotrlik, and Higgins (2001), was determined to ensure representativeness of the population surveyed. A sample size estimate with 5% error and an alpha level of 0.05 was calculated considering a population of all national final year physiotherapy students (n ≈ 600) and physiotherapists (n = 10.000). Thus, a minimum sample size of 187 students and of 264 physiotherapists was established.

Data collection
A questionnaire developed by Reeve et al. (2012) was used as a model to facilitate comparisons with previous studies. The questionnaire was slightly adjusted during a pilot testing conducted in two sessions, one with eight physiotherapy students and another one with eight physiotherapists. Each session started by sending the hyperlink to the participants and giving them time to complete the questionnaire. At the end, a focus group was conducted with each group. An independent researcher with experience in leading focus groups facilitated both sessions. The questions required participants to provide feedback on presentation, design, structure, and organization of the survey; clarity, adequacy, and comprehensiveness of the questions; and suggestions for improvement. Focus groups lasted between 60 and 90 min and were audio-recorded and transcribed verbatim. After piloting, minor changes regarding the formatting, organization, and cultural expression adaptations of the questionnaires were performed. Data from piloting were not included in this study.
A final version of both questionnaires was reached (Appendices 1 and 2), where the first page provided general information about the study. Digital consent was obtained by clicking on the "agree" box in the second page of the survey.
The students' survey was divided into six sections (Appendix 1) (Reeve et al., 2012): (1) general data, (2) clinical placement information, (3) physiotherapy career intentions, (4) interest or not in CRP specialization, (5) opinions of CRP, and (6) general questions and suggestions. The physiotherapists' survey was divided into the following four sections (Appendix 2): (1) general data, (2) physiotherapists working in the cardiorespiratory area, (3) physiotherapists not working in the cardiorespiratory area, and (4) general questions and suggestions. Most questions were of a closed or categorical nature, using 5point Likert scales, but offering participants an opportunity to comment openly where appropriate.

Data analysis and response rates
Data were exported from LimeSurvey to Excel and then to Statistical Package for Social Sciences version 22 for statistical analysis. Closed questions were analyzed and presented using descriptive statistics. A systematic approach to the analysis of the open questions was used and common themes, concerns, and suggestions were identified following a methodology previously used by others (Reeve et al., 2012). These questions were summarized by one researcher and doublechecked by a second researcher.
A total of 210 physiotherapy students from the 18 institutions (35% response rate) and 545 physiotherapists (14% response rate) responded to the survey. Twenty-one physiotherapy students consented but submitted the survey without responses and therefore, 189 questionnaires were considered for analyses. Forty-four physiotherapists did not digitally consent, and 126 consented but submitted the survey without responses and therefore, 375 questionnaires were included in the analyses.
Most questionnaires presented missing data, unevenly distributed along participants. Thus, to avoid unnecessary loss of information, incomplete questionnaires were not discharged, but results were reported considering the total valid answers for each question (e.g., if 144 students reported having had at least 1 CRP placement, but only 186 out of the total 189 students answered this particular question, then the result would be reported as "n = 144, 77%" since 144/186 = 0.774). Subgroup analyses comparing male and female responses from students and physiotherapists, and urban (i.e., >5000 inhabitants) and nonurban (i.e., rural and semi-urban, ≤5000 inhabitants) responses from physiotherapists only, since all institutions providing the physiotherapy degree to students are based in urban areas, were also conducted using the Chi-squared association test for nominal data, the Chi-squared Mantel-Haenszel linear by linear association test for ordinal data, and the t-test for continuous data.

Physiotherapy career intentions
The largest proportion of students were "extremely interested" in specializing in musculoskeletal physiotherapy (n = 59; 33%). The CRP area was the second least popular with only 23 (13%) students being "extremely interested" and 32 (18%) reporting "no interest at all" in specializing ( Figure 1).

Interest or not in CRP specialization
Students who responded that they were at least a little interested in specializing in CRP (n = 150; 82%) reported that the factors that most positively influenced their interest were "interesting aspects about CRP" (n = 110; 80%) and "clinical exposure/experience" (n = 99; 72%). Factors reported to have had no influence in their interest were "influence of others" (n = 97; 71%) and potential salary (n = 94; 69%) ( Figure 3).

Opinions of CRP
Opinions regarding the main factors for not pursuing a career in CRP were "having greater interest in another area of physiotherapy" (n = 61; 46%), "few job opportunities in the region" (n = 47; 35%), and "never having had a placement in CRP during the physiotherapy program" (n = 11; 8%). When asked if anything could influence them to choose specializing in CRP, most students answered negatively (n = 154; 85%).
Students were asked to give suggestions regarding changes in the physiotherapy curriculum to improve the appeal for CRP (i.e., organization of the clinical exposure/ experience, style and organization of the curriculum of the course, and preparation of the clinical educators/lecturers) and a content analysis of the 128 responses was conducted. To facilitate the readers' understanding of these suggestions, a brief description of the physiotherapy curriculum is provided. In Portugal, the undergraduate physiotherapy degree has 4 years. Although there is a wide variety across the different institutions, the most common organization/ structure is to have basic sciences (i.e., anatomy and physiology), human movement, and introduction to physiotherapy where some of the basis of physiotherapy are taught during the first year, and musculoskeletal and neurological physiotherapy in the second year. Third year revisits aspects of the musculoskeletal area and approaches CRP. Fourth year provides a comprehensive integration of the different areas with complex clinical case management and research projects. Clinical placements occur commonly in the second semester of the second, third, and fourth years and students are allocated to a place from a list of clinical placements provided by each institution which are not commonly organized by physiotherapy areas or, in some specific cases in the final year of the degree, they may be able to independently find themselves a clinical placement. The undergraduate level does not provide any specialization. Specialty paths (i.e., musculoskeletal, neurologic, respiratory, cardiovascular, sports, pediatrics, and geriatrics) are individually chosen at a postgraduate level in academic institutions although they are not currently recognized in the healthcare systems.
Fifty-five (43%) students reported that CRP should become an obligatory area for at least one clinical placement and this exposure should occur during the second or third years of the course and not in the fourth year ". . .when students have already made up their minds about what area they want to pursue. . ." [Gil,22 years]. Students (n = 20, 16%) also reported the need for . . .more clinical placements for CRP, as a significant proportion of students are still finishing their courses without knowing what CRP really is . . . but these should be in different contexts, so each student can then decide if they want to work in paediatrics, intensive care, pulmonary rehabilitation etc. . .. I think that most of us do not know the real potential and importance of this area. . .. [Anna,20 years] Ten students (8%) also reported the need for all institutions to integrate CRP in their curriculum ". . .there are still schools which do not have specific CRP units, this should not be allowed if the idea is to increase the interest in the area. . .." [John 23 years]. Specific suggestions for improvement and to motivate students to pursue the area were given. Increasing the number of practical lectures (n = 35; 27%), allowing the contact with real patients during the lectures (n = 20; 16%), and conducting final year research projects in the CRP area (n = 10; 8%) were reported as being "crucial." Fifteen (12%) students also reported the need to increase the knowledge and preparation of lecturers and supervisors in this field.

Comparisons between genders
Gender groups provided similar responses in all items except for the one concerning the specialization area. The musculoskeletal was reported as the area of most interest to specialize by both genders although male students showed greater interest than females (p < 0.001). Female students also showed a positive interest for geriatrics (p = 0.001), CRP (p = 0.005), and neurology (p = 0.007) or a similar interest (positive or negative) by pediatrics (p = 0.001) and community (p = 0.013), while males showed a negative interest by all areas, except by neurology and community, where the demonstrated interest was similar.

Physiotherapists
Physiotherapists working in the cardiorespiratory area Physiotherapists working in CRP (n = 55; 15%) considered that their mentors/role models (n = 38; 69%) and interest in CRP (n = 45; 82%) were the personal factors that most influenced in their decision to pursue a career in CRP. Forty-nine (89%) physiotherapists reported that having knowledge of CRP practice prior to entering the physiotherapy program had little or no influence in their decision. Other personal factors influencing their career choice were personal preferences (n = 7; 58%), family issues (n = 2; 17%), residence location, good relationship with patients or with fellow practitioners (n = 3; 25%). The professional factors most influencing physiotherapists' choice to pursue a career in CRP were the "opportunity to work with patients in an acute setting" (n = 35; 64%), "interprofessional practice" (n = 31; 56%) and "job availability" (n = 30; 55%). Flexible employment was the professional factor that most little or no influence had in their decision (n = 50; 91%). Other professional factors reported were job accessibility (n = 9; 33%), being a challenging and measurable area (n = 9; 33%), being an unexplored area in Portugal (n = 6; 22%), and having CRP experience within the undergraduate course (n = 3; 11%).
From all previous factors (personal and professional), the three that most contributed to physiotherapists' decision to pursue a career in CRP were interest in CRP practice (n = 37; 67%), opportunity to work with patients in an acute setting (n = 31; 56%), and mentorship/role model (n = 25; 46%) ( Table 2).
Physiotherapists not working in the cardiorespiratory area Physiotherapists not working in CRP (n = 320; 85%) considered that personal and professional factors had little or no influence in their decision in not to pursue a career in CRP. Nevertheless, personal preference for other areas (n = 67; 85%) was the personal factor mostly reported; however, economic difficulties to further develop knowledge in the area (n = 10; 13%) and health problems (n = 2; 3%) were also mentioned. Other professional factors influencing their career choice were the lack of job availability (n = 96; 73%), lack of demand by patients (n = 27; 21%), and being an area undertaken by other health professionals (n = 6; 5%).
From all previous factors, the three that most contributed to physiotherapists' decision not to pursue a career in CRP were other professional factors (n = 177; 58%), lack of postgraduate opportunities (n = 140; 46%), and narrow scope (i.e., lack of variation/routine/not interesting) (n = 101; 33%) ( Table 2).

General questions and suggestions
Suggestions for improving the interest in CRP focused on raising awareness of the CRP role to increase job vacancies (n = 35; 55%): . . .very few people know what a physiotherapist is and even less know that a CRP exist and what we can do for them. . . therefore, there are no jobs and if people don't know about us, even if they need us, how can they give us a job?. . . [Sara,44 years] Fifteen (23%) physiotherapists reported the need to improve the availability of postgraduate courses in CRP ". . .there are postgraduate courses in almost all physiotherapy areas, and very little offer and even less of high quality on the CRP area. . .." [Richard 37 years]. Eight (13%) physiotherapists also mentioned the need to dedicate more time (hours) to the CRP area and using "case-based approach" during students' education and training to improve their clinical reasoning, knowledge, and skills.

Comparisons between gender and urban/non-urban areas
Gender differences were only found for the area of preference (p = 0.007) and area of work (p = 0.047). Although male and female preferred and were working mostly in the musculoskeletal area, females' responses were more evenly spread over all physiotherapy areas.

Comparisons between physiotherapists and students
Influence of prior knowledge in the decision to pursue or not a career in CRP Most students (n = 120, 66%) reported having no knowledge about CRP prior to commencing the physiotherapy undergraduate program. Additionally, 148 (78%) students stated not knowing which area they would like to work in after graduating and 76 (40%) students reported a change in their choice during their physiotherapy training. According to the physiotherapists working (n = 49; 89%) and not working (n = 259; 81%) in CRP, having prior knowledge about CRP had little or no influence in their decision to work or not in CRP.

Areas of specialization
Students were extremely interested in specializing in the musculoskeletal (n = 59, 33%) and neurology (n = 40; 22%) areas; however, the CRP area was the second least preferred (23 [13%] students reported being extremely interested and 32 [18%] showed no interest). Physiotherapists followed the same interests as students, referring the musculoskeletal area as the one they mostly identified themselves with (n = 145, 39%) and the one in which they developed most of their work (n = 153; 41%). However, CRP (n = 83; 22% and n = 59; 16%) moved up in the preference list appearing ahead of neurology (n = 55; 15% and n = 52; 14%) in both questions.
Influence of factors in the decision to pursue or not a career in CRP Regarding the factors influencing the choice of a career in CRP, students (n = 110; 80%) and physiotherapists (n = 45; 82%), mostly assigned a positive influence to the "interesting aspects of the area." "Job accessibility" was rated with a moderate positive influence by both students (n = 56, 41%) and physiotherapists (n = 30; 55%). "Influence of others," in particular of "teachers and mentors," was reported to have a positive influence on physiotherapists (n = 38; 69%); however, students reported much less positive influence (n = 29; 21%) and mostly considered no influence of others on their choice (n = 97; 71%). When asked directly about having been influenced by a role model/mentor on their decision, 73 (54%) students answered "Yes."

Discussion
This study showed that 13% of physiotherapy students were "extremely interested" in specializing in CRP and only 34% knew the CRP area before commencing their course. Having interest in the area and clinical exposures/ experiences were the main positive factors influencing students to pursue a career in CRP, while having interest in another area, few job opportunities, and lack of clinical exposure were the factors that most negatively influenced students. Our findings also showed that only 15% of the participating physiotherapists were working in the CRP area. Their decision to pursue a CRP career was most influenced by their own interest in the area, the opportunity to work with patients in an acute respiratory setting, and having role models/educators. The factors that most contributed not to pursue a CRP career by most physiotherapists were other professional factors (e.g., lack of job availability and lack of demand by patients), lack of postgraduate opportunities, and narrow scope of practice. Musculoskeletal was the preferred physiotherapy area by males and females in students and professionals; however, females showed a more equally distributed interest by the different physiotherapy areas. Physiotherapists working in urban areas were more experienced, had more postgraduate training and a higher CRP caseload than those working in non-urban areas.
Similarly to our study, previous research reported that 26-32% students knew about CRP before commencing their course (Janaudis-Ferreira et al., 2016;Reeve et al., 2012) and only 0.5-12.5% were extremely interested in specializing in CRP (Janaudis-Ferreira et al., 2016;Öhman, Stenlund, and Lars, 2001;Reeve et al., 2012;Roskell and Cross, 2003), even after having had a positive contact/experience with the area during the course. This is already being reflected in the small number of physiotherapists working in CRP as shown in our results.
Although there are no studies in this field, it is believed that the lack of knowledge and interest in CRP may be related to the history and development of the physiotherapy profession. Physiotherapy emerged, in the nineteenth century, closely linked to natural remedies and simple physical agents needed for musculoskeletal rehabilitation during world wars and the poliomyelitis epidemic (Klinteberg, 1992). For these reasons, the physiotherapy core of practice has been associated to musculoskeletal injuries. Currently, with the increasing life expectancy, aging, and lifestylerelated diseases, the initial therapeutic concept has expanded to cover a wide range of physiotherapy specialties, in which CRP is included since 1978 (Swisher, Sciaky, Campbell, and Lowman, 2008). Nevertheless, musculoskeletal continues to be the most well-known area of the physiotherapy practice. In recent reports, medical respondents have shown awareness of physiotherapy benefits in the management of musculoskeletal disorders (Chioma, 2007;; however, the benefits of physiotherapy in cardiorespiratory disorders or in any other disorders were never mentioned. Similarly, a survey inquiring patients' knowledge and attitudes toward physiotherapy has shown that 60-70% of respondents had limited knowledge of physiotherapy in general and of its different areas (Webster, Holdsworth, McFadyen, and Little, 2008). Even among physiotherapy students (Öhman, Solomon, and Finch, 2002;Öhman, Stenlund, and Lars, 2001) and professionals (Bergman, 1989;Johansson, 1999), males or females, the main interest has focused on musculoskeletal and sports areas; however, in the future, intervention needs will be in broaden areas as the worldwide population is aging (Öhman, Stenlund, and Lars, 2001). Thus, there is a need to raise academic and public awareness about physiotherapy and its different areas of action. A special emphasis should also be given to increase awareness and interest of physiotherapy students for the CRP area, given the major health, economic, and social burden of the NCD worldwide (World Health Organization, 2017), and the ideal skills of these professionals to manage lifestyle-related conditions. Patient education and exercise training are hallmarks of physiotherapy practice and these interventions are effective in preventing, managing, and, in some cases, reversing lifestyle-related conditions (Dean, 2009a(Dean, , 2009bDean et al., 2014). Nevertheless, assessment and intervention strategies directed to these conditions in CRP practice and curriculums are minimal not just in Portugal but also around the world (Dean et al., 2011(Dean et al., , 2014Roskell, 2013). As shown by our data and by similar findings previously reported (Hussey et al., 2017;Reeve et al., 2012), approximately 25% of students have never had a CRP clinical placement; there are still physiotherapy curriculums where CRP modules are absent and there is a misconception of the narrow scope of this area. But the fact is that a paradigm shift has occurred in the modern society, and the cardiorespiratory area has nowadays a much broader scope of action that most people have not yet recognized. Cardiorespiratory is no longer just about assessing and treating acute cardiorespiratory conditions but it is also about the assessment and treatment of lifestyle-related conditions (Reeve et al., 2012;Roskell, 2013). CRP now includes treating respiratory or cardiovascular patients in acute, primary, and tertiary contexts and it involves exercise interventions and education, advice, and health promotion (Reeve et al., 2012). Therefore, there is a need to reflect this scope of action in the physiotherapy curricula and to integrate interprofessional collaborative education and practice opportunities in both undergraduate and graduate programs (Lindqvist et al., 2005;Morgan, 2017).
In fact, more than half of the time of physiotherapists' clinical practice is now spent on interprofessional activities (Hylin, Nyholm, Mattiasson, and Ponzer, 2007), which in this study was felt as one of the main professional factors influencing physiotherapists to pursue a career in CRP. It is well established that health promotion and management of chronic conditions depends on an effective collaborative interprofessional practice. Nevertheless, the current protectionism around professions promotes more isolation, elitism, and territorialism than creates and protects professional identity. Thus, attending to CRP current scope of action and to the motivation of physiotherapists to pursue a CRP career seem essential to promote interprofessional activities from graduation onwards. Within this context, there is a need to alter the perceptions of physiotherapy students and physiotherapists, as well as the curriculum from curative orientation toward a curriculum that addresses health promotion functions and psychosocial aspects of healthcare delivery (Nolte and McKee, 2008;Roskell, 2013). This comprehensive curriculum will reduce the role of profession-centrism (Pecukonis, 2014), increase health professionals' understanding about each other's work, and decrease the feelings of fear and anxiety about their role being taken by others (McNeil, Mitchell, and Parker, 2013), thus enhancing professional practice and enriching professional identity. Ultimately, these changes will help to develop an adequate workforce that will contribute not only to improve the quality of life and well-being of patients and families but also to enhance professional practice (Morgan, 2017), professional identity, and acceptance of others through collaborative practice in modern times (World Health Organization, 2010).
Similarly to previous studies, clinical exposure was considered as an important factor influencing students to specialize in CRP (Hussey et al., 2017;Janaudis-Ferreira et al., 2016;Reeve et al., 2012). It has been shown that students feel less confident in CRP when compared to other specialties (Roskell and Cross, 2003), simply because they are not often exposed to the area. It has been called the "theory-practice gap," which reduces the effectiveness of the learning environment and the attractiveness of a specialty (Roskell and Cross, 2003). In fact, a study of physiotherapists' education (Hunt, Adamson, and Harris, 1998;World Health Organization, 2017) reported that students lacked knowledge of the "world of work," indicating that clinical practice represents a powerful element within the "hidden curriculum" of professional socialization with confidence (Roskell and Cross, 2003). This idea was also corroborated by physiotherapists, who reported that one of the most influencing factors to pursue a career in CRP was their clinical role models and educators. In the context of health care, role models and educators are mentors that serve as a valuable resource to bridge the gap between theory and practice (Lafleur and White, 2010). The literature contains little guiding evidence to determine the most appropriate method of mentor-mentee interactions (Yoon et al., 2017). This suggests that there is not a "one-size-fitsall" approach to mentorship relationships and that outcomes may be optimized by using an individualized approach to the interaction (Yoon et al., 2017). This relationship should be further valued as it is known that mentoring affects career productivity, satisfaction (Sambunjak, Straus, and Marusic, 2010), perception of confidence and is one of the most important features for the development of expertise among physiotherapists (Sambunjak, Straus, and Marusic, 2010;Shepard, Hack, Gwyer, and Jensen, 1999). Therefore, our findings emphasize the need of those involved in higher education and clinical practice to provide opportunities for better integration with the clinical practice in this specialty in order to lessen the gap between theory and practice, realizing their vital role in encouraging students to pursue careers in CRP and contributing for the future of CRP worldwide.
Home care, geriatric or community care were the least popular areas for specialization, as previously reported (Janaudis-Ferreira et al., 2016;Öhman, Solomon, and Finch, 2002;Reeve et al., 2012). In this line, a small percentage of physiotherapists identified themselves with or were working in these areas. However, healthcare policies advocate shifting health care from hospitalized settings into the community or home (Nolte and McKee, 2008). This is likely to increase the demand of physiotherapists and hence job opportunities in these areas. Nevertheless, as demonstrated by our findings, to consider these areas as viable career options, students need to be exposed to positive educators, clinical role models, and evidence-based knowledge, acquire a broader understanding of health-care issues, become familiar with community-based care, and be prepared to work in these settings (Nolte and McKee, 2008). This exposure must also include rural areas, since residents of rural communities tend to experience poorer health outcomes and exhibit higher health needs. Therefore, workforce shortages and maldistribution mean that rural communities do not have access to the range of services available in urban areas (Adams, Jones, Lefmann, and Sheppard, 2015), but it also means that they are an area of opportunity for physiotherapists to expand their range of action.
Strategies suggested to increase the profile of CRP were similar to those previously reported and consisted of (1) including modules and at least one specific clinical placement in CRP within the physiotherapy curriculum (Hussey et al., 2017;Reeve et al., 2012); (2) adjusting physiotherapy curricula to emphasize health promotion and management of lifestyle risk factors (Dean et al., 2014); (3) creating opportunities to develop CRP skills in broaden contexts (such as primary/community/home care) and settings (rural vs. urban areas), and implementing these skills in different health conditions (Dean et al., 2014;Hussey et al., 2017;Nolte and McKee, 2008;Reeve et al., 2012); and lastly (4) developing health promotion activities to the community, health professionals, and students to increase awareness about the role of CRP on the management of lifestyle conditions and clarify misconceptions (Janaudis-Ferreira et al., 2016;Reeve et al., 2012). Moreover, our findings also suggest that the development of advanced training within the CRP may enhance the attractiveness of the area (Pitta et al., 2014;Roskell and Cross, 2003).

Limitations of the study
The surveys were disseminated via the contacts of the institutions offering an undergraduate physiotherapy program and the national physiotherapy association; thus, it cannot be guaranteed that all final-year students and physiotherapists have received the links. However, people were also encouraged to share the links among their contacts to minimize any potential bias of this disseminating method and reminders were sent to minimize the lack of response. Additionally, the voluntary nature of participation in an online survey might have influenced results as it is likely that participants already had some opinion about CRP.
Another potential limitation is that the work regime was not questioned and therefore, answers of full-time and part-time physiotherapists could not be differentiated. Different results might have been found if this comparison was conducted and therefore, questioning about work regime should be considered in future studies.
Moreover, in this study, interest to pursue or not a career in CRP and personal and professional factors were explored; however, participants were not specifically asked about their personal preferences (e.g., fast pace, and ability to apply physiology to treatments). In future studies, personal preferences could be explored, namely in qualitative studies so that a more in-depth understanding of the participants' reasons to pursue or not a career in CRP can be obtained. There were also two different questionnaires being used to facilitate comparisons with other international studies; however, this hindered comparisons between students and physiotherapists. In the future, studies using the same or matching questionnaires would be important to obtain a more comprehensive analysis of both samples. Finally, in the case of students, all institutions providing physiotherapy training were located in urban areas; therefore, it remains unknown whether students trained in non-urban areas would provide different responses. In future studies, including this data may enhance our understanding of the CRP education and practice.

Conclusion
This study has showed that a small percentage of the physiotherapy students and physiotherapists identified CRP as an area of present or future practice. Given the major health, economic, and social burden of the NCD worldwide and the ideal skills of CRP to manage lifestylerelated conditions, it seems important to change students' and physiotherapists' perspectives about CRP. Strategies focusing on changing the physiotherapy curriculum structure and focus, increasing students' exposure to CRP practice in different contexts, settings and conditions, providing good mentorship models, developing health promotion activities directed to the community, health professionals, and students, and creating high-quality postgraduate courses may increase the attractiveness for CRP.