Participants
Characteristics of the 49 GPs who participated in the study (12 interviews, six focus groups) are presented in Table 1.
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Using deductive and inductive categorisation approaches, we developed 13 main thematic categories, which were further differentiated into 28 subcategories. The complete coding tree has been published at OSF (https://osf.io/yj9dr/, translated into English).
According to the research aims of the present study, we report the main results of three thematic categories, which we consider central: 1) experience with PA advice for patients with IHD, 2) perception (including affective and cognitive components) on PA advice for patients with IHD, and 3) attitude on PA advice for patients with IHD.
The original quotations (translated into English) for the summarised results are shown in Table 2–4.
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Experience – Advice on PA
Reasons for providing PA advice, initiative and procedure of advising
PA advice is mostly perceived as time-consuming, not prioritised and not a routine part of GPs consultations with patients with IHD (quote 1a, Table 2). Other issues seem to dominate the routine care of these patients, like the discussion of latest laboratory results and the provision of medication (quote 1b, Table 2).
When PA advice is provided it usually takes place during regular consultations, e.g., as part of routine DMP appointments and in conversations which are perceived as an opportunity to discuss lifestyle issues, such as a deterioration of blood parameters (primarily the Low Density Lipoprotein (LDL) value) (quote 1c, Table 2). However, other health behaviours (e.g., diet) are often prioritised over PA.
GPs seem to have different views on the appropriate moment to provide PA advice. Some favour such a conversation shortly after the occurrence of an IHD-related cardiovascular event, e.g., myocardial infarction, when patients seem to be more receptive for behaviour change interventions. Others favour routine consultations at later times distant to the cardiac event (quote 1d and e, table 2).
Procedures to deliver PA advice differ. Some GPs recommend (more) PA without further explanation or specific recommendations (quote 1f, table 2). Others ask about the current PA situation and/or explore their patient’s environment to identify individual opportunities for PA (quote 1g, table 2).
It turns out that some GPs have very complex ideas about how to advise on PA (e.g., complicated, time-consuming and difficult to implement) and mentioned this as a reason for not regularly advising on PA, as it is not feasible in everyday practice (quote 1h, table 2). Others have noted that they are offering PA advice at a lower frequency because the advice has not been effective according to their experience (quote 1i, table 2).
Few GPs questioned the evidence for health benefits of PA in IHD, which was then also mentioned as a reason for not providing PA advice (quote 1j).
Specific recommendations on PA
Almost all GPs who reported to provide PA advice tend to give more general rather than specific recommendations to their IHD patients with regard to type, duration and intensity of PA (quote 2a, table 2).
When more specific recommendations are given, these often relate to the integration of PA into daily life (e.g., use the bike instead of the car), moderate physical activities (e.g., walking, cycling), and/or individual and group activities (quote 2b and c, table 2). Especially for patients with sedentary behaviour and/or mobility restrictions, the principle is ‘the main thing is to do at least something’ (quote 2d, table 2).
Referrals to providers of PA programmes (e.g., physiotherapy, cardiac training groups) seem to be rather popular, because of patients who are worried about their IHD, feel anxious about, or have little experience with PA (quote 2e and f, table 2).
When recommending PA, GPs rarely differentiate between PA intensities (moderate vs. intensive PA, information about maximum heart beat, quote 2g, table 2). In addition, delivered recommendations often do not seem to meet current guideline recommendations on PA levels, durations and intensities (e.g., WHO recommendations [3]).
Some GPs who give little or no advice on PA describe a lack of knowledge about specific individual recommendations and local PA programmes to refer to (quote 2h, table 2).
Communication strategies
Different communicative narratives (framing strategies) are used consciously and subconsciously to recommend PA to patients with IHD. For example, on the one hand benefits and positive outcomes (gain framing) of PA are emphasised (e.g., improving quality of life, quote 3a, table 2). On the other hand, some GPs mentioned possible negative consequences (loss framing) of PA (e.g., possibility of other diseases, quote 3b, table 2). These examples are often found in combination with content-related explanations of the effects of PA (content framing) using explanatory models, pictorial descriptions and statistical or narrative evidence of PA (quote 3c, table 2). Another communication strategy mentioned is to emphasise the patient's responsibility, e.g., to family members (responsibility framing, quote 3d, table 2).
The statements of the GPs show different types and intensities of appeals they seem to make to their patients, like emotional appeals and appeals for action to motivate patients to PA (quote 3e, table 2). Those addressing PA more frequently seem to reiterate the importance of PA for the patients’ heart disease (quote 3f, table 2).
Some GPs attempt to tailor the conversation to the individual (personalisation/tailoring). A frequently reported example of this is building on positive experiences with PA from the past (quote 3g, table 2).
Barriers and facilitating factors
GPs report organisational factors facilitating the implementation of PA advice by creating routines and pre-planned time slots (e.g., structures created within the practice, standardised processes, and the provision of PA advice to patients with appointments (DMP consultations), i.e. not during acute consultation hours, quote 4a, table 2).
In order to address PA, a trusting atmosphere for this perceived sensitive topic and the authenticity of GPs, with references to their own PA behaviour, difficulties and motivation, is experienced to be advantageous (quote 4b, table 2).
Also an often long-standing relationship to patients and knowledge of personal circumstances are seen as beneficial for the discussion of health behaviour (quote 4c, table 2).
Techniques for focused and short conversations on PA are also mentioned as advantages and are needed at the same time (quote 4d, table 2). Infographics and risk scores (actually developed in the context of primary prevention of IHD) are sometimes used to reinforce what has been said on health benefits of PA (quote 4e and f, table 2).
GPs describe barriers towards the provision of PA advice as a lack of knowledge about the evidence for PA in IHD, lack of concrete knowledge about the content of individual and specific recommendations regarding type, duration and intensity of PA, and a lack of control parameters – comparable to blood or blood pressure levels – to objectify the PA level. Translating medical information on IHD in patient-oriented language and the beneficial effects of PA in a patient-centred way is also perceived to be difficult. A lack of knowledge on advice techniques and arguments tailored to the target group were also identified as barriers. GPs report to lack tools to facilitate the beginning of a conversation on PA and to provide a basis for discussion (e.g., self-assessment PA questionnaires and questionnaires on PA motivation) (quote 4g, h and i, table 2). Comorbidities (e.g., limited mobility) of patients also hinder the provision of specific advice (quote 4j, table 2).
GPs report that – compared to other diseases – physiological parameters that are determined in the context of IHD, e.g., heartrate, LDL, do not or only to a limited extent reflect ‘patient cooperation’ in relation to PA in disease management, which is experienced as a disadvantage (quote 4k, table 2).
On a structural level GPs describe a lack of professional discourse about PA, combined with a perceived lower value compared to interventional or pharmacological therapy in the medical discourse as a barrier (e.g., perceived lack of support for ‘talking medicine’, neglect of presentation and discussion of PA-related effects on IHD in medical trainings or lectures/conferences) (quote 4l and m, table 2).
Perception – Advice on PA
Perception includes affective and cognitive components. For many of the participating GPs, the provision of PA advice is not perceived as a pleasant or enjoyable conversation. They perceive and describe themselves as ‘fun killers’, some feel like they are ‘talking to a brick wall’ (quote 1a and b, table 3).
GPs perception of frustration plays a central role with the frequency of providing PA advice and is caused by redundant dialogue content, lack of sense of progress due to recommendations not being implemented or rejected by patients. This leads to a decrease in consulting activity, which is explained by the management of one's own emotions, e.g., self-protection from negative feelings, and the loss of motivation (quote 1c and d, table 3).
The perception of frustration is closely linked to the experience of self-efficacy. GPs report to be pleased to receive confirmation when patients change their behaviour in response to their advice. According to this, it is perceived as a positive experience if the GPs effectiveness is confirmed or reflected in the patient's state of health (‘therapeutic success’) (quote 1e, table 3).
The perception of fear, e.g., of treatment errors and specific PA recommendations that could put patients at risk (e.g., for a myocardial infarction), also seem to play a decisive role as a barrier (quote 1f, table 3).
Self-reflection of own PA advising skills
Some of the participating GPs are satisfied with their PA advice skills, although this tends to refer to their counselling skills in general (quote 2a, table 3).
When being asked about PA advice, most GPs said they found this challenging and more difficult than advising on other health behaviours (e.g., diet, quote 2b, table 3). Also their provision of PA advice is perceived as incomplete and in need of improvement (e.g., lack of implemented/structured PA referral schemes, quote 2c, table 3). In particular, GPs sometimes find it difficult to give personalised and patient-centred PA advice (quote 2d and e, table 3).
Attitude – Advice on PA
Personal role/ideal
While some GPs feel that PA advice cannot be seen as an original responsibility of GPs (quote 1a, table 4), the majority of participants note that it is a rather secondary part of the ‘overall package’ of GP care for patients with IHD (quote 1b and c, table 4).
Even if PA advice is seen as an important task and responsibility of general practice by some participants and/or the evidence of PA in IHD is known, it is not ensured that PA advice will be provided (quote 1d, table 4). It is also mentioned that, unlike other care services, the willingness to provide PA advice is determined by one's own attitude and commitment to PA and PA advice (quote 1e, table 4). The majority of the participating GPs believe that PA advice should be given by people who (enjoy) being physically active and who can therefore act as authentic role models (quote 1f, table 4).
In relation to their understanding of their role, GPs formulated different tasks and functions that they see in the context of their medical work with regard to PA advice, e.g., pointing out PA opportunities and existing PA programmes (quote 1g, table 4), acting as motivators for their patients to become more active (quote 1h, table 4), or as supporters who emphasise a partnership-based relationship with patients when it comes to PA advice (quote 1i, table 4).
While some GPs appear to be frustrated when patients do not follow their recommendations, the majority of participating GPs say that in theory they distance themselves from the patients’ action in response to their advice (quote 1j and k, table 4).
Aims of PA advice
Reported objectives of PA advice focus on knowledge transfer, including the promotion of disease awareness by explaining risks and consequences of physical inactivity, the positive health outcomes of regular PA, and by enabling a better understanding of the link between PA and IHD (quote 2a and b, table 4).
In addition, the communication of realistic PA goals, in some cases in connection with the identification of individual resources and appropriate programmes, are identified as direct goals of PA advice (quote 2c and d, table 4). Some of the participating GPs also aim to provide feedback to their patients on their PA level (quote 2e table 4).
In the reflection of their self-given tasks, several participating GPs reveal underlying intentions such as improving quality of life and maintaining independence (in old age) of patients through regular PA (quote 2f and g, table 4).