A total of 28 individuals (n=14 HPs and n=14 patients) participated in the qualitive interviews therefore nearly reaching our target sample size of 30 and achieving saturation of themes. Participant demographics are presented in Table 1. Participants were represented across genders for both HPs and patients. A diverse age range was achieved for patients (33-72yrs) and smaller range for HPs (38-56yrs). HP participants included both general practitioners (GP) (64.3%) and practice nurses (35.7%). Self-reported physical activity levels identified the majority of HPs (92.9%) and patients (57.1%) describing being active at least 3 days per week.
Table 1: Participant Demographics
Healthcare Professionals (n=14)
|
Patients (n=14)
|
Variable
|
n (%)
|
Variable
|
n (%)
|
Gender
|
Gender
|
Female
|
7 (50.0)
|
Female
|
8 (57.1)
|
Male
|
7 (50.0)
|
Male
|
6 (42.9)
|
Age
|
Age
|
25-34
|
0 (0.0)
|
25-34
|
2 (14.3)
|
35-44
|
4 (28.6)
|
35-44
|
1 (7.1)
|
45-54
|
8 (57.1)
|
45-54
|
5 (35.7)
|
55-64
|
2 (14.3)
|
55-64
|
2 (14.3)
|
>65
|
0 (0.0)
|
>65
|
4 (28.6)
|
Role
|
|
General Practitioner
|
9 (64.3)
|
Practice Nurse
|
5 (35.7)
|
Physical Activity Level (Days per week)
|
Physical Activity Level (Days per week)
|
0
|
0 (0.0)
|
0
|
3 (21.4)
|
1-2
|
1 (7.1)
|
1-2
|
3 (21.4)
|
3-4
|
5 (35.7)
|
3-4
|
1 (7.1)
|
5-6
|
4 (28.6)
|
5-6
|
4 (28.6)
|
7
|
4 (28.6)
|
7
|
3 (21.4)
|
Both patients and HPs were asked about whether they had previously or regularly had discussions about physical activity with their HP/patients. HPs mainly stated this occurring ‘often’, ‘all the time’ or even daily, however, for the majority of the patients they answered that the HP had not mentioned improving physical activity that they could remember but did frequently describe conversations about body weight that often linked to physical activity.
Connecting primary care patients to jogscotland: Professional and patient views regarding potential methods
Interviews with both HPs and patients revealed various potential methods of connecting patients to community-based jogscotland groups. We have categorised these into three: informal passive signposting, informal active signposting, and formal referral/prescribing, based on the type and level of workload associated with the processes of connection for the HP. Each of these methods can be implemented in multiple ways (Figure 1) and for the patient, can involve varying levels of associated workload, that is, low level; - following referral they are contacted by an intermediary person/third party with more details, or a higher workload level; - that is, patient self-refers to seek further information following signposting or prescribing.
Figure 1: Three potential methods of connecting patients to community-based groups from primary care with examples of how these can be implemented
Both patients and HPs acknowledged that advertising local physical activity opportunities such as jogscotland could easily be achieved at the GP practice as well as throughout the wider community. The use of posters and leaflets as well as the television monitors in the practice waiting areas could provide a passive means of sharing knowledge of what is available locally and what the group involves:
“Like a short video, you know how you can run a rotational thing in practices? If people are just sitting in a waiting room, instead of them just sitting there, they’re watching a 30 second, ‘welcome to jogscotland, this is what we do’. I don’t know.” [Health Professional, 52yrs, Male]
Patients and HPs additionally discussed the formal prescribing of physical activity:
“Actually, being able to say, ‘I’m going to prescribe you, x, y and z, and you need to be at this place, at this time, or here’s the contact details’. I think that would be useful. I think it would be a bit more of a formal structured way of being able to hand that advice on. People might also feel like… People like to have something in their hand to go out the door with, and so, often, from our point of view, that means a prescription for a drug. If we can give them a prescription for something that isn’t a drug, that would be a good thing, I think.” [Health Professional, 42yr, male]
“Would they be more open to it, or would being prescribed a course of physical activity, to somebody who had never done it, be actually more advantageous to them? … It’s an interesting question, because in actual fact, when you look at it, it may be that somebody has never, ever thought about it. They’ve maybe thought, ‘I can’t do that at all’, so it just is totally discounted. You might be opening up a new possibility for some people.” [Patient, 67yr, male]
For HPs, referring patients on to an intermediary (e.g. link worker or exercise co-ordinator) to discuss their physical activity options in more detail and in a personalised manner was also an attractive method:
“From a GP’s perspective, if we were able to refer somebody [to] a physical exercise coordinator, who was then able to go through with a patient the types of problems they have, the types of things they like doing, how they would like to change, what sort of exercise they’d like to do, and then give them a structured bit of advice. I think that would be a good way forward.” [Health Professional, 42yr, male]
It is noteworthy that, when discussing being ‘referred’ by a HP, patients often included and described examples of informal active signposting, where the HP speaks to them about increasing their physical activity levels and prompts them towards different types of activities or resources. Within the method of active signposting, HPs and patients often discussed ‘just having the conversation’ and the use of leaflets and contact cards as a means of emphasising the conversation about improving physical activity. This was seen to allow people to consider their options and remind them that they can self-refer:
“I think contact you know a leaflet and contact card or something like that would be preferable to just verbally told about it because it jogs, you know jogs the memory when you get home you take it out your pocket and go right, I’ll do something about that.” [Patient, 34yrs, Male]
“I could give something, hand something over to the patient a bit like we hand over our prescriptions. That interaction of handing something over I think is more powerful than me telling them I think. So, again there are other things that I could be doing I think more actively that might... then that then sits on their table and they might then say, ‘oh, I’ll go and do that,’ so, rather than it being in their brain and then disappearing after a few hours of leaving.” [Health Professional, 38yrs, Male]
Professional and patient views regarding barriers and facilitators to the identified methods of connection
For both HPs and patients, the barriers and facilitators to connecting patients can be described to arise in two contexts: a) within the raising of the topic of physical activity and b) in connecting patients to the physical activity opportunity. Views from HPs and patients are presented separately in accordance to their analysis approach.
Health Professional Views
For HPs, the barriers and facilitators for connecting patients to physical activity opportunities, such as jogscotland, fell within five domains of the TDF: knowledge; memory, attention & decision processes; environmental context and resources; social/professional role and identity; beliefs about consequences (Figure 2). These domains mapped across all three components of the COM-B model highlighting that the HPs capability (knowledge and decision-making process), opportunity (environmental context & resources), and motivation (social/professional role & identify and beliefs of consequences) were important determinants within their behaviour.
Figure 2: HP barriers and facilitators to connecting patients to community-based physical activity opportunities.
Memory, attention and decision processes
For the HPs, their real-time decision-making on whether to raise the issue of physical activity with their patients was guided by how the interaction unfolded and their rapport with the patient during the consultation. Many HPs describe that their decision on whether to raise the topic of physical activity improvement involved waiting for an opening or opportunity when the patient establishes for themselves that physical activity and lifestyle factors could help improve health complaints. This patient-led raising of the topic then acts as the opening opportunity for the HP:
“So, when somebody’s decided their condition requires them to go to a doctor and they’re in front of a doctor then I can certainly raise it. But I don’t usually push it at people until they come to me and say, ‘well, listen, you know’, and then that gives me the ideal opportunity.” [Health Professional, 50yr, male]
However, HPs acknowledged that this patient-driven approach does not always work:
“One of the problems that we have is that often, if we try to empower patients to identify contributing factors, so if we try to say to people who’ve got… Let’s say somebody’s got a back pain, and we think they should be more active, and we say, ‘is there anything that you think might be contributing to this?’ or ‘is there anything that you could do differently or change in the way you live your life that might help?’. Often, people say ‘no, there’s not’. So, they identify the fact that what we’re trying to get at is, you should lose some weight and be more active, but rather than saying it in that way, we’re trying to do it in a more empowering, more patient-centred way. But often it doesn’t work, that’s the problem.” [Health Professional, 42yr, male]
Thus, HPs are the main instigators of discussions concerning physical activity, and whether or not they decide to do so is often determined by their perception of the patients’ receptivity and openness to the topic.
Beliefs about consequences
Many of the HPs expressed that their decision regarding whether or not to discuss physical activity with their patients depended on their beliefs about the patients’ engagement and confidence in improving their physical activity levels. In particular, many HPs discussed that their perception that patients would action their suggestion to improve their own health through increased physical activity was a significant consideration when deciding whether or not to raise the issue during a consultation:
“it’s getting the time, from what I understand, it’s getting the patient at the right time, when they’re motivated, when they're ready to take some change.” [Health Professional, 45yr, female]
“You are trying with these people, but a lot of them, I think they’re looking for that medication, rather than to engage with others and do self-help.” [Health Professional, 53yr, female]
HPs also described that many patients didn’t think that the physical activity opportunities available in their areas were for them:
“I think for physical activity, like say the [medical condition-specific physical activity programme], and the cardio gym I think sometimes people feel that exercise isn’t for them.” [Health Professional, 53yr, female]
This perception of the patient’s intentions and beliefs towards physical activity often impacted on HPs’ decisions regarding whether or not to raise the topic. These beliefs were also considered alongside the HPs’ perceptions about the barriers to physical activity for their patients, such as lack of time, availability and accessibility:
“There’s the cost thing as well, most people don’t seem to have that much money to go join a gym or to a regular class or sign up to a running club. There’s all that.” [Health Professional, 49yr, female]
“There are people who struggle to access things that involve travel or effort or being organised.” [HP11, 50yr, male]
Knowledge, environmental context & resources
HPs identified lack of knowledge and time to discuss physical activity with patients as a barrier. Furthermore, access to resources advising what physical activity options are available in the area and time to seek out this information is a critical barrier for HPs:
That’s the irony of it, you know, frontline healthcare professionals who are working to 10-minute consultations, you struggle with the accessibility and currency of information. [Health Professional, 50yrs, Male]
To facilitate and help to overcome these barriers, HPs often described the need for up-to-date resources and alternative connecting solutions that rely on an intermediary person or external resource, including; - practice champions, link workers/co-ordinators within practices, and community hubs for broader social prescribing:
“I think there’s probably an opportunity with community health and social care hubs, that’s part of what they could potentially do is to signpost people and keep the intelligence on what’s available and what does it do.” [Health Professional, 50yr, male]
“I guess the other thing is to have champions in each practice. And that wouldn’t necessarily need to be a clinician. It could be people in admin. Or you could have, you know, more than one. So, people who, you know, could disseminate some information and stuff to the others. That would be quite good, wouldn’t it?” [Health Professional, 56yr, female]
Social/professional role and identity
HPs acknowledge their perceived position of influence and responsibility can be utilised to positively motivate patients towards improving their physical activity levels:
“I think health professionals have a responsibility to do that. I don’t think we’re the only people that can do it, and I don’t think it should be our sole task or job, but I think there’s an opportunity there, if someone comes along with something that could be helped, or… By improving physical activity, or it could be, in fact, triggered by not being physically active, I think there’s a responsibility to bring that up.” [Health Professional, 42yr, male]
However, HPs often raised the point that clinicians should not be solely responsible, and in fact many HPs felt that physical activity should not be medicalised but normalised:
“I think of it as take it out of the medical practice. De-medicalise it, make it part of normal life, okay it was me that triggered it but unshackle the medicalisation of it.” [Health Professional, 50yr, male],
The HPs often discussed both that the responsibility lies within the wider community and society as well as with the patient who needs to take ownership for their own health.
For some HPs, there was a medico-legal concern for connecting patients to local opportunities such as jogscotland, where the HPs lack of knowledge about the suitability and content of these local physical activity groups led to concerns:
“How do I know I’m referring to something appropriate and not a danger to my patients.” [Health Professional, 38yr, male]
Patient views
For patients the barriers and facilitators identified fell within the COM-B components of motivation and opportunity.
Motivation
The majority of patients described being open to physical activity discussions with their HP. Patients share the view with HPs that the HP is in a role and position of influence and can act as a motivator and facilitator by connecting them to physical activity options:
“think I’d be more encouraged to do something like that, them [HP] saying, ‘you need to increase your walking’. I would maybe say, ‘okay, I’ll take the dogs out five days a week and that will increase my walking by two and a half times,’ or ‘I’ll make sure I go for a walk every weekend for two and a half…’ And that’s something you would commit to, because the doctor has said to you, you’ve got to do that.” [Patient, 64yr, female]
Importantly, patients often discussed the dislike of being dictated to and that in particular, the formal prescribing of physical activity may not be always be taken positively by some patients. In contradiction however, many patients discussed the legitimacy of being ‘referred’ to something by their HP:
“I think it’s something I would be more inclined to try if I was sort of referred to it. I know that sounds ridiculous…I don’t know. It’s hard to put into words. I think it would just, it sounds silly, but I would just feel more justified in going along if I was being told to go basically. Although I know we, as human beings, hate being told to do things as well. Maybe not being absolutely dictated to that I had to go, but if I was referred to it, I’d feel it was just a more legitimate thing to do if that makes sense.” [Patient, 50yr, female]
Patients acknowledged that a discussion about physical activity (and other lifestyle factors) with their HP can give them motivation and can trigger the ‘little push’ towards them thinking and actioning on the advice/suggestion to improve their activity levels:
“Aye, when he sort of brought it up [discussion on improving physical activity] I was, sort of, went home and I was thinking to myself, I was like my jeans are a bit tight on me. And I just started noticing things like that. Then I was like ‘right I’m going to do something about it.’ Give myself something to aim for.” [Patient, 33yr, male]
Patients value HPs as potential motivators and facilitators towards physical activity. Central to this belief is the importance patients place on the ability of HPs to link the benefits of improved physical activity to their health and/or medical conditions combined with the way they approach the topic. Similar to HPs, patients discussed that how the topic is raised by the HP and the perceived responsiveness of a patient to the issue of improving physical activity is key:
“I think, I think you have to sort of be careful on what you’re doing on that side of things. Because if you have got people that’s on a bit of a downer and that as well, then the fact that you’re sort of putting that across to them as well that ‘you need to lose a bit of weight’ or anything like that, then that could sort of trigger more off. You could get people going away and they could start sulking more. And thinking ‘that doctor’s called me fat’.” [Patient, 33yr, male]
“I suppose, getting people… it’s putting the message across without making people feel guilty for not doing exercise, is one of the most important things” [Patient, 43yr, female]
Opportunity
Patients often liked the option of being connected to resources on specific physical activity opportunities by their HP for them to consider and potentially follow-up on. Patients described that connecting to tangible options is favourable because they perceive it as helping them towards implementing the changes in their physical activity instead of generically being told ‘you should get more active’ without any discussion of options:
“Having something tangible that the GP’s group can recommend, rather than, ‘we think you should get a bit more physical activity’.” [Patient, 68yr, female]
Participants in some of the interviews suggested that the opportunity to meet with organisers and members of a local jogscotland group could allow patients to ‘meet and greet’ with local physical activity groups in their area. This potential option was then raised by researchers in latter interviews with patients to ask their views. Patients often described that a ‘meet and greet’ (potentially held at a local community location or even the health centre/healthcare practice) could provide them the opportunity to ask questions of what is involved and to meet with people before turning up for the first time – a barrier often mentioned by many individuals during the interviews when they consider starting or turning up to a physical activity opportunity:
“A meet and greet might be good then I wouldn’t mind going along to that on my own. If there was maybe other people going at the same time I’d think, ‘oh, we’re all joining together that’d be fun.’ And the chances are you might see someone you recognise so that meet and greet might be okay.” [Patient, 63yr, female]
Having the social support to go along to one of these local jogscotland groups was often mentioned by the patients, and by the HPs, as acting as a means to help motivate and support patients towards taking the first step towards activity. Furthermore, it was mentioned by patients that a ‘buddy system’ could be useful to help in this support:
“I was going to say, not that I’ve ever been to Alcoholics Anonymous, I know I’ve got a bit of a food addiction, but I know they’ll have their sponsors. So maybe they could buddy up with somebody who really does take a keen interest in where you’re at, and wants to help you monitor your progress, motivate you, and all the rest of it, then that might be quite an idea.” [Patient, 50yr, female]