Facilitators and barriers
Table 3 summarizes clinician and patient behavioural determinants from the review articles. Behavioural determinants have been grouped according to their respective domains and further sub-categorized as facilitators and barriers to patient exercise adherence.
Capability
The main themes identified for patient capability were knowledge, skills, and exercise perceptions. Types of health knowledge included: knowledge of personal health and health conditions 12, 18, 22, 27, 29, suitable PA intervention strategies 12, 19, 23, 25, 27–29, PA guidelines 28, 29, and benefits of PA for their well-being 12, 18, 19, 27, 29. Two main forms of behavioural regulation skills were noted in several articles to influence behaviour, these being action-planning and action-control 19, 21, 24–26, 29, 31. Action-planning was defined as being able to make detailed plans on how to complete target behaviour, while action-control was defined as the automaticity to control habits leading to target behaviour 21. Moreover, these two skills were often grouped together and categorised as a single psychological capability factor for behavioural regulation in the articles. Contrarily, a lack of behavioural regulation skills resulted in lower levels of exercise adherence as patients forgot to do exercises, and/or only engaged in PA when they remembered to 24. Ayton et al. 18 also noted that a perceived lack of time was a barrier to engaging in intervention programs, which may be attributed to a lack of behavioural regulation 17. In addition, negative exercise perceptions, such as a dislike of exercise 15, 31 and a fear of exercise 15, 18, were noted to be psychological Capability barriers.
Opportunity
External themes identified were in the context of the patient’s physical and social environment. Multiple studies involving patients and clinicians identified a lack of access to resources and services as an opportunity barrier 17, 18, 25, 27, 31. High costs of resources and services was also stated as a barrier for patients in five studies 18, 23, 25, 27, 28, whereas affordable facilities resulted in greater adherence levels 12, 28, 31. A prominent physical opportunity determinant noted in multiple articles was the availability of time for engaging in PA 12, 17, 18, 22, 23, 25, 27, 28, 30. Thus, inadequate time for PA is likely not limited to specific patient populations or demographics. A common reason stated ‘for lack of time’ was commitments to other priorities such as work and family 15, 17, 18, 22, 23, 25, 28. In terms of social opportunity, family and friends were social facilitators in seven studies 15, 17, 22–25, 27, while five studies 15, 20, 23, 25, 27 had peer support as a facilitator. Conversely, a lack of social support opportunities was cited in four studies as a barrier to treatment adherence 19, 20, 30, 31.
Motivation
The main theme identified for Motivation was the development of autonomous patient motivation. Strong beliefs about capabilities (self-efficacy) were identified as strong facilitators developing autonomous motivation for patients in six studies 12, 15, 21, 26, 28, 29, whereas weak beliefs about capabilities was a motivational barrier in five studies 19, 20, 23, 25, 27. Beliefs about social role and identity influenced beliefs about self-capabilities and had significant effects on exercise adherence 21, 25. Two common facilitators of autonomous motivation were high intentions towards behavioural change 21, 25, 26, 29, 31, and the use of goal setting 15, 21, 25, 29, 31. Other sources of motivation included: incentives to exercise such as rewards and positive health outcomes 12, 24, 29, 31, and enjoyment of exercise and physical activity 17, 21, 31. In addition, twelve studies 12, 15, 17, 18, 21–25, 27–29, 31 found high perceived personal relevance to be associated with increased determination to engage in exercise behaviour. In contrast, nine studies 12, 15, 18, 20, 23, 27, 28, 30, 31 found patients with misconceptions about PA and their health conditions had lower exercise adherence. Common indications for high levels of perceived personal relevance included symptom control, and desire for better health and overall well-being.
Clinician strategies for facilitating patient adherence
In the context of Capability, three studies suggested the use of educational material by clinicians to increase their patients’ health literacy and increase exercise adherence 18–20. Clinicians interviewed in three studies also placed emphasis on the importance of effective communication skills to relate information to patients and facilitate behaviour change 13, 14, 16. It was further suggested that clinicians consider the patient’s prior experiences with physical activity during exercise prescription, as patients were less inclined to adhere to their programs when prescribed with unsuitable exercises 17.
Opportunity variables identified for clinicians were primarily extraneous and outside of the clinician’s control. These consisted of environmental variables such as: the patient’s life situation 12, 13, time allocated with the patient 13, 14, 16, patient access to intervention resources and services 14, 16, 17, 19, 20, and subjective social norms13, 14, 16.
With regards to motivation, clinicians commonly stated the use of a patient-centred approach as a facilitator 12, 15, 19, 20. Four studies 15, 18–20 cited the use of education, albeit focusing on making the information relevant to a patient for increasing patient perceived-relevance. In addition, two studies 12, 18 involving older adults found that patients responded more positively when the intervention details focused on positive aspects and health benefits.