Theoretical Domains Framework Domains Research Articles

Drivers of district-level differences in outpatient antibiotic prescribing in Germany: a qualitative study with prescribers

BackgroundPrevious studies have identified substantial regional variations in outpatient antibiotic prescribing in Germany, both in the paediatric and adult population. This indicates inappropriate antibiotic prescribing in some regions, which should be avoided to reduce antimicrobial resistance and potential side effects. The reasons for regional variations in outpatient antibiotic prescribing are not yet completely understood; socioeconomic and health care density differences between regions do not fully explain such differences. Here, we apply a behavioural perspective by adapting the Theoretical Domains Framework (TDF) to examine regional factors deemed relevant for outpatient antibiotic prescriptions by paediatricians and general practitioners.MethodsQualitative study with guideline-based telephone interviews of 40 prescribers (paediatricians and general practitioners) in outpatient settings from regions with high and low rates of antibiotic prescriptions, stratified by urbanity. TDF domains formed the basis of an interview guide to assess region-level resources and barriers to rational antibiotic prescription behaviour. Interviews lasted 30–61 min (M = 45 min). Thematic analysis was used to identify thematic clusters, and relationships between themes were explored through proximity estimation.ResultsBoth paediatricians and general practitioners in low-prescribing regions reported supporting contextual factors (in particular good collegial networks, good collaboration with laboratories) and social factors (collegial support and low patient demand for antibiotics) as important resources. In high-prescribing regions, poor coordination between in-patient and ambulatory health services, lack of region-level information on antimicrobial resistance, few professional development opportunities, and regional variations in patient expectations were identified as barriers to rational prescribing behaviour.ConclusionsInterventions targeting professional development, better collaboration structures with laboratories and clearer and user-friendly guidelines could potentially support rational antibiotic prescribing behaviour. In addition, better networking and social support among physicians could support lower prescription rates.

Understanding delays in chronic limb-threatening ischaemia care: Application of the theoretical domains framework to identify factors affecting primary care clinicians' referral behaviours.

Patients in the community with suspected Chronic limb-threatening ischaemia (CLTI) should be urgently referred to vascular services for investigation and management. The Theoretical Domains Framework (TDF) allows identification of influences on health professional behaviour in order to inform future interventions. Here, the TDF is used to explore primary care clinicians' behaviours with regards to recognition and referral of CLTI. Semi-structured interviews were conducted with 20 podiatrists, nurses and general practitioners in primary care. Directed content analysis was performed according to the framework method. Utterances were coded to TDF domains, and belief statements were defined by grouping similar utterances. Relevance of domains was confirmed according to belief frequency, presence of conflicting beliefs and the content of the beliefs indicating relevance. Nine TDF domains were identified as relevant to primary care clinicians: Knowledge, Environmental context and resources, Memory, Decision and attention processes, Beliefs about capabilities, Skills, Emotions, Reinforcement and Behavioural regulation. Relationships across domains were identified, including how primary care clinician confidence and working in a highly pressurized environment can affect behaviour. We have identified key barriers and enablers to timely recognition and referral behaviour. These beliefs identify targets for theory-driven behaviour change interventions to reduce delays in CLTI pathways.

Reducing risk behaviours after stroke: An overview of reviews interrogating primary study data using the Theoretical Domains Framework.

Lifestyle changes, in addition to preventive medications, optimise stroke secondary prevention. Evidence from systematic reviews support behaviour-change interventions post-stroke to address lifestyle-related risk. However, understanding of the theory-driven mediators that affect behaviour-change post-stroke is lacking. Electronic databases MEDLINE, Embase, Epistemonikos and Cochrane Library of Systematic Reviews were searched to March 2023 for systematic reviews addressing behaviour-change after stroke. Primary studies from identified systematic reviews were interrogated for evidence supporting theoretically-grounded interventions. Data were synthesized in new meta-analyses examining behaviour-change domains of the Theoretical Domains Framework (TDF) and secondary prevention outcomes. From 71 identified SRs, 246 primary studies were screened. Only 19 trials (N = 2530 participants) were identified that employed theoretically-grounded interventions and measured associated mediators for behaviour-change. Identified mediators mapped to 5 of 14 possible TDF domains. Trial follow-up ranged between 1-12 months and no studies addressed primary outcomes of recurrent stroke or cardiovascular mortality and/or morbidity. Lifestyle interventions targeting mediators mapped to the TDF Knowledge domain may improve the likelihood of medication adherence (OR 6.08 [2.79, 13.26], I2 = 0%); physical activity participation (OR 2.97 [1.73, 5.12], I2 = 0%) and smoking cessation (OR 10.37 [3.22, 33.39], I2 = 20%) post-stroke, supported by low certainty evidence; Lifestyle interventions targeting mediators mapping to both TDF domains of Knowledge and Beliefs about Consequences may improve medication adherence post-stroke (SMD 0.36 [0.07, 0.64], I2 = 13%, very low certainty evidence); Lifestyle interventions targeting mediators mapped to Beliefs about Capabilities and Emotions domains may modulate low mood post-stroke (SMD -0.70 [-1.28, -0.12], I2 = 81%, low certainty evidence). Limited theory-based research and use of behaviour-change mediators exists within stroke secondary prevention trials. Knowledge, Beliefs about Consequences, and Emotions are the domains which positively influence risk-reducing behaviours post-stroke. Behaviour-change interventions should include these evidence-based constructs known to be effective. Future trials should address cardiovascular outcomes and ensure adequate follow-up time.

Improving medication dispensing and counselling for patients with vision impairment: a qualitative study of pharmacist-reported barriers and facilitators

BackgroundPeople with vision impairment encounter many difficulties when it comes to medicines use. However, evidence indicates that there are major gaps in pharmaceutical care service provision worldwide and limited research on interventions to optimise medication use for this patient population. The Theoretical Domains Framework (TDF) provides a method for theoretically understanding individuals’ behaviour and informing development of interventions. The aim of this research was to (a) identify the barriers and facilitators to the provision of medication dispensing and counselling services by pharmacists to patients with vision impairment, and (b) identify key TDF domains to be targeted in a future intervention.MethodsSemi-structured interviews were conducted with pharmacists from different pharmacy practice settings/areas in Saudi Arabia. The 14-domain TDF was utilised as the theoretical lens through which pharmacists’ behaviours were examined. Interviews were conducted in Arabic or English, either face-to-face or over the telephone based on the participant’s preference. Following transcription, interviews conducted in Arabic were translated into English before analysis. Data analysis involved using the framework method and content analysis to identify important barriers and facilitators to the provision of dispensing and counselling services to those with vision impairment. Key TDF domains that could be targeted in a future intervention were then identified using a consensus-based approach.ResultsTwenty-six pharmacists were interviewed. Pharmacists’ experience in pharmacy practice ranged from two to 28 years. A range of barriers and facilitators were highlighted as important in providing services to those with vision impairment. Eight domains were identified as ‘key domains’ including: ‘Knowledge’, ‘Skills’, ‘Beliefs about capabilities’, ‘Goals’, ‘Memory, attention, and decision processes’, ‘Environmental context and resources’, ‘Social influences’, and ‘Behavioural regulation’.ConclusionsBarriers and facilitators identified by pharmacists will inform the development of an intervention to ensure its applicability to everyday practice. Future research will focus on the process of developing the proposed intervention through targeting key TDF domains to improve medication dispensing and counselling by pharmacists to patients with vision impairment.

Designing a primary care pharmacist-led review for people treated with opioids for persistent pain: a multi-method qualitative study.

Opioids are frequently prescribed for persistent non-cancer pain despite limited evidence of long-term effectiveness and risk of harm. Evidence-based interventions to address inappropriate opioid prescribing are lacking. To explore perspectives of people living with persistent pain to understand barriers and facilitators in reducing opioids in the context of a pharmacist-led primary care review, and identify review components and features for optimal delivery. Primary care multi-method qualitative study. Adults with experience of persistent pain and taking opioids participated in semi-structured interviews (n=15, 73% female) and an online discussion forum (n=31). The Theoretical Domains Framework (TDF) provided a framework for data collection and thematic analysis, involving deductive analysis to TDF domains, inductive analysis within-domains to generate subthemes, and subtheme comparison to form across-domain overarching themes. The behaviour change technique taxonomy v.1 and motivational behaviour change technique classification system were used to systematically map themes to behaviour change techniques to identify potential review components and delivery features. 32 facilitator and barrier subthemes for patients reducing opioids were identified across 13 TDF domains. These combined into six overarching themes: learning to live with pain, opioid reduction expectations, assuming a medical model, pharmacist-delivered reviews, pharmacist-patient relationship and patient engagement. Subthemes mapped to 21 unique behaviour change techniques, yielding 17 components and five delivery features for the proposed PROMPPT review. This study generated theoretically-informed evidence for design of a practice pharmacist-led PROMPPT review. Future research will test the feasibility and acceptability of the PROMPPT review and pharmacist training.

Barriers and enablers to a healthy lifestyle in people with infertility: a mixed-methods systematic review

While there is a recognised role of optimising lifestyle behaviours such as diet and physical activity in the management of infertility, the best practice for lifestyle management of infertility remains unknown, and factors influencing the lifestyle behaviours of people with infertility are not well understood. The aim of this systematic review is to evaluate the barriers and enablers to a healthy lifestyle in people with infertility, from the perspectives of people with infertility and health professionals, in order to inform optimal behavioural change strategies for lifestyle management of infertility. Ovid MEDLINE(R), PsycINFO, EMBASE, EBM Reviews, and CINAHL Plus were searched from inception to 12th September 2022. Eligible studies were qualitative, quantitative or mixed-methods primary studies which explored barriers and/or enablers to lifestyle for infertility management, from the perspectives of people with infertility and/or health professionals. Two independent reviewers performed quality assessment, using the Centre for Evidence-Based Management Critical Appraisal of a Survey Tool (quantitative and mixed-methods studies) and the Critical Appraisal Skills Programme Qualitative Checklist (qualitative and mixed-methods studies). Data were analysed by inductive thematic analysis with themes mapped to the Capability, Opportunity, Motivation and Behaviour (COM-B) model(1) and Theoretical Domains Framework (TDF)(2). Relevant behaviour change techniques (BCTs)(3) to target the identified enablers and barriers were suggested. After screening 10703 citations and 82 full-texts, 22 studies were included (12 quantitative, 7 mixed-methods and 3 qualitative) with 18 studies including women with infertility (n = 2442), 10 including men with infertility (n = 1372) and 6 including health professionals (n = 261). From the perspectives of people with infertility, themes related to capability (e.g. strategies for behaviour change), opportunity (e.g. limited time, resources and money) and motivation (e.g. interplay between lifestyle and emotional state); themes mapped to 8 TDF domains. From the perspectives of health professionals, themes related to capability (e.g. identification of patients appropriate for lifestyle intervention), opportunity (e.g. mode of delivery) and motivation (e.g. professional responsibility); themes mapped to 6 TDF domains. 34 BCTs were identified across the suggested interventions. This systematic review found that several interacting factors influence lifestyle in people with infertility as well as health professional behaviour with regards to provision of lifestyle interventions for infertility. These factors can be targeted for optimisation of interventions. In light of the limited number of qualitative studies, there is a need for more qualitative research to gain deeper insights into the perspectives of people with infertility and health professionals for further exploration of the complex and interacting factors which shape lifestyle during the fertility journey.

Exploring attitudinal barriers to participation in inpatient fall risk assessment using the Theoretical Domains Framework: A survey of providers.

Lack of provider (physicians and advanced practice providers)participation in fall risk assessment was theorized to be contributing to rising rates of falls with injury at our institution. This project sought to identify if attitudinal barriers to inpatient provider participation in fall risk assessment were similar to those identified in other clinical settings. Barriers to provider participation in fall risk assessment were identified in the literature. These were mapped to the Theoretical Domains Framework (TDF) domains to assist with interpretation of the data. A 10-item survey using a 5-point Likert scale (strongly agree to strongly disagree) with two open-ended questions was developed using these barriers. The survey was distributed via email to all providers on the Medical Staff in July 2021. The response rate was 9.1% (188/2062). 72.6% (95% confidence interval [CI]: 65.6, 78.5) of providers at our institution did agree that fall risk assessment was within their role and 72% (95% CI: 66.1, 78.5) agreed that assessment can prevent falls. Nearly half felt that they lacked formal training in fall risk assessment (48.1% [95% CI: 41.1, 55.1]) and 52.2% (95% CI: 44.6, 58.6) agreed that other aspects of patient care took priority over fallsassessment. These barriers correlated best with the TDF domains of Beliefs about Capabilities and Beliefs about Consequences. Survey results indicate that interventions focused on increasing provider motivation and capability regarding fall risk assessment and helping providers prioritize fall risk assessment are potential targets for future quality improvement projects.

Mapping the potential of meal kits to influence parental food literacy: an application of behaviour change frameworks

Cooking at home and eating together provide opportunities to improve family nutrition and promote healthy dietary habits. Commercial meal kit subscription services (MKSSs) (e.g. HelloFresh™, Marley Spoon™, EveryPlate™) may support parents to overcome obstacles to family meal provisioning and facilitate food literacy development. A gap exists in our understanding of how and why meal kits may elicit behaviour change, and opportunities to increase their behaviour change capability. This study aimed to examine the theoretical potential of Australian MKSSs to promote parental food literacy using the Behaviour Change Wheel (BCW)(1) and associated Theoretical Domains Framework (TDF)(1) and Behaviour Change Technique Taxonomy v1 (BCTTv1)(2). A one-week subscription was purchased for all Australian-based MKSSs (n = 9) and key meal kit components (subscription and meal planning features, meal kit delivery and website content) were coded using the retrospective application of these behaviour change frameworks. Parental food literacy-related behaviours were informed by a Food Literacy framework(3). Identified BCTs were mapped to the TDF using the Theory and Techniques Tool to identify theoretical mechanisms of action. The key meal kit components identified mapped to eight of the nine BCW intervention functions. These components primarily served the functions of enablement and environmental restructuring to support cooking at home. Thirty-five of the 93 possible BCTs were identified across the nine MKSSs reviewed, ranging from 19 to 29 BCTs per company, and linked to 13 of the 14 TDF domains. The most frequently identified mechanisms of action (TDF) targeted changes in motivation (n = 27) and capability (n = 19) to influence parental food literacy. Australian-based MKSSs incorporate a wide range of BCTs that target mechanisms of action associated with food literacy-related behaviours. These findings provide a strong theoretical evidence-base for the potential of commercial MKSSs to enhance parental food literacy. However, the extent to which these services may influence behaviour change or impact family food intakes is currently unknown. Therefore further research is required to evaluate the healthfulness and effectiveness of MKSSs.

Digital screening for mental health in pregnancy and postpartum: A systematic review.

This systematic review aimed to determine if digital screening for mental health in pregnancy and postpartum is acceptable, feasible and more effective than standard care (paper-and pen-based screening or no screening). The second aim was to identify barriers and enablers to implementing digital screening in pregnancy and postpartum. OVID MEDLINE, PsycINFO, SCOPUS, CINAHL, Embase, Web of Science, Joanna Briggs Database and All EMB reviews incorporating Cochrane Database of Systematic Reviews (OVID) were systematically searched for articles that evaluated digital screening for mental health in pregnancy and postpartum between 2000 and 2021. Qualitative articles were deductively mapped to the Theoretical Domains Framework (TDF). A total of 34 articles were included in the analysis, including qualitative, quantitative and mixed-methods studies. Digital screening was deemed acceptable, feasible and effective. TDF domains for common barriers included environmental context and resources, skills, social/professional role and identity and beliefs about consequences. TDF domains for common enablers included knowledge, social influences, emotion and behavioural regulation. When planning to implement digital screening, consideration should be made to have adequate training, education and manageable workload for healthcare professionals (HCP's). Organisational resources and support are important, as well as the choice of the appropriate digital screening assessment and application setting for women. Theory-informed recommendations are provided for both healthcare professionals and women to inform future clinical practice.

What influences stroke survivors with physical disabilities to be physically active? A qualitative study informed by the Theoretical Domains Framework.

Although the benefits of regular physical activity (PA) after stroke are well established, many stroke survivors do not achieve recommended PA levels. To date, studies exploring determinants to PA have not used a behaviour change theory and focused on stroke survivors with physical disabilities. As a precursor to an intervention development study, we aimed to use the Theoretical Domains Framework (TDF) to identify factors influencing PA in stroke survivors with physical disabilities in Singapore. Between November 2021 and January 2022, we conducted interviews with 19 community-dwelling stroke survivors with a weak arm and/or leg. An interview guide based on the TDF was developed. We analysed the data deductively by coding interview transcripts into the theoretical domains of the TDF, and then inductively by generating themes and belief statements. To identify relevant TDF domains, we prioritised the domains based on the frequencies of the belief statements, presence of conflicting belief statements and evidence of strong belief statements. Eight of the 14 TDF domains were relevant, and included environmental context and resources, knowledge, social influences, emotion, reinforcement, behavioural regulation, skills and beliefs about capabilities. The lack of access, suitable equipment and skilled help often limited PA participation at public fitness spaces such as parks, gyms and swimming pools (environmental context and resources). While a few stroke survivors expressed that they had the skills to engage in regular PA, most expressed not knowing how much and how hard to work, which exercises to do, which equipment to use and how to adapt exercises and equipment (knowledge and skills). This often left them feeling afraid to try new activities or venture out to new places for fear of the unknown or adverse events (e.g., falls) (emotion). For some, doing the activities in a group encourage them to get out and engage in PA (social influences). In stroke survivors with physical disabilities, environmental context and resources had a significant influence on PA participation, and this often had a spill over effect into other domains. Our results inform a complex behaviour change intervention to improve PA after stroke, and has implications for intervention design for people with physical disabilities.

Nonclinical factors affecting intraoperative red blood cell transfusion: a systematic review.

There is significant variability in intraoperative red blood cell (RBC) transfusion practice. We aimed to use the theoretical domains framework (TDF) to categorize nonclinical and behavioural factors driving intraoperative RBC transfusion practice in a systematic review of the literature. We searched electronic databases from inception until August 2021 to identify studies evaluating nonclinical factors affecting intraoperative RBC transfusion. Using the Mixed Methods Appraisal Tool, we assessed the quality of included studies and identified relevant nonclinical factors, which were coded into TDF domains by two independent reviewers using NVivo (Lumivero, QSR International, Burlington, MA, USA). We identified common themes within domains and sorted domains based on the frequency of reported factors. Our systematic review identified 18 studies: nine retrospective cohort studies, six cross-sectional surveys, and three before-and-after studies. Factors related to the social influences, behavioural regulation, environmental context/resources, and beliefs about consequences domains of the TDF were the most reported factors. Key factors underlying the observed variability in transfusion practice included the social effects of peers, patients, and institutional culture on decision-making (social influences), and characteristics of the practice environment including case volume, geographic location, and case start time (environmental context/resources). Studies reported variable beliefs about the consequences of both intraoperative transfusion and anemia (beliefs about consequences). Provider- and institutional-level audits, educational sessions, and increased communication between surgeons/anesthesiologists were identified as strategies to optimize intraoperative transfusion decision-making (behavioural regulation). Our systematic review has synthesized the literature on nonclinical and behavioural factors impacting intraoperative transfusion decision-making, categorized using the TDF. These findings can inform evidence-based interventions to reduce intraoperative RBC transfusion variability. Open Science Framework ( https://osf.io/pm8zs/?view_only=166299ed28964804b9360c429b1218c1 ; first posted, 3 August 2022).

Planting the seeds for success: A qualitative study exploring primary healthcare providers' perceptions about medical cannabis.

In Canada, cannabis legalization altered the way that the public can access cannabis for medical purposes. However, Canadians still struggle with finding healthcare professionals (HCPs) who are involved in medical cannabis counselling and authorization. This raises questions about the barriers that are causing this breakdown in care. Our study explored the perceptions of primary care providers regarding cannabis in their practice. Semi-structured interviews were conducted by Zoom with HCPs in Newfoundland and Labrador (NL) to discuss their experiences with medical and non-medical cannabis in practice. Family physicians and nurse practitioners who were practicing in primary care in NL were included. The interview guide and coding template were developed using the Theoretical Domains Framework (TDF). A thematic analysis across the TDF was then conducted. Twelve participants with diverse demographic backgrounds and experience levels were interviewed. Five main themes emerged including, knowledge acquisition, internal influences, patient influences, external HCP influences, and systemic influences. The TDF domain resulting in the greatest representation of codes was environmental context and resources. The findings suggested that HCPs have significant knowledge gaps in authorizing medical cannabis, which limited their practice competence and confidence in this area. Referring patients to cannabis clinics, while enforcing harm-reduction strategies, was an interim option for patients to access cannabis for medical purposes. However, developing practice guidelines and educational resources were suggested as prominent facilitators to promote medical cannabis authorization within the healthcare system.

Reducing Postoperative CT Imaging for Children With Complicated Appendicitis: A Pediatric Surgical Quality Collaborative Quality Improvement Project

BackgroundDespite widespread initiatives to reduce ionizing radiation for appendicitis diagnosis, computed tomography (CT) scanning postoperatively remains common. The Pediatric Surgery Quality Collaborative (PSQC) aimed to identify differences between children’s hospitals with high and low postoperative CT usage for complicated appendicitis. MethodsUsing National Surgery Quality Improvement Program Pediatric data from PSQC children’s hospitals, we compared postoperative CT imaging for complicated appendicitis (April 2020-March 2021). Key stakeholders from 11 hospitals (5 low CT utilization, 6 high CT utilization) participated in semi-structured interviews regarding postoperative imaging. Qualitative analysis of transcripts was performed deductively and inductively based on the Theoretical Domains Framework (TDF). ResultsFive of twelve TDF domains were most prominent in influencing CT use: skills, beliefs about capabilities, intentions/goals, memory and decision processes, and environment. Children’s hospitals with lower rates of postoperative CT use tended to: trust and educate the ultrasound technicians; believe US strengths outweigh weaknesses; image no sooner than 7 days postoperatively; have access to sufficient quality improvement resources; maintain trusting relationships between specialties; and prioritize radiation stewardship. ConclusionHospitals at extremes of postoperative CT use for complicated appendicitis reveal strategies for improvement, which include imaging protocol development and adherence, quality improvement resource availability, interdisciplinary collaboration, and promoting radiation stewardship. Level of Evidencelevel V.

Key influences on university students’ physical activity: a systematic review using the Theoretical Domains Framework and the COM-B model of human behaviour

BackgroundPhysical activity is important for all aspects of health, yet most university students are not active enough to reap these benefits. Understanding the factors that influence physical activity in the context of behaviour change theory is valuable to inform the development of effective evidence-based interventions to increase university students’ physical activity. The current systematic review a) identified barriers and facilitators to university students’ physical activity, b) mapped these factors to the Theoretical Domains Framework (TDF) and COM-B model, and c) ranked the relative importance of TDF domains.MethodsData synthesis included qualitative, quantitative, and mixed-methods research published between 01.01.2010—15.03.2023. Four databases (MEDLINE, PsycINFO, SPORTDiscus, and Scopus) were searched to identify publications on the barriers/facilitators to university students' physical activity. Data regarding study design and key findings (i.e., participant quotes, qualitative theme descriptions, and survey results) were extracted. Framework analysis was used to code barriers/facilitators to the TDF and COM-B model. Within each TDF domain, thematic analysis was used to group similar barriers/facilitators into descriptive theme labels. TDF domains were ranked by relative importance based on frequency, elaboration, and evidence of mixed barriers/facilitators.ResultsThirty-nine studies involving 17,771 participants met the inclusion criteria. Fifty-six barriers and facilitators mapping to twelve TDF domains and the COM-B model were identified as relevant to students’ physical activity. Three TDF domains, environmental context and resources (e.g., time constraints), social influences (e.g., exercising with others), and goals (e.g., prioritisation of physical activity) were judged to be of greatest relative importance (identified in > 50% of studies). TDF domains of lower relative importance were intentions, reinforcement, emotion, beliefs about consequences, knowledge, physical skills, beliefs about capabilities, cognitive and interpersonal skills, social/professional role and identity, and behavioural regulation. No barriers/facilitators relating to the TDF domains of memory, attention and decision process, or optimism were identified.ConclusionsThe current findings provide a foundation to enhance the development of theory and evidence informed interventions to support university students’ engagement in physical activity. Interventions that include a focus on the TDF domains 'environmental context and resources,' 'social influences,' and 'goals,' hold particular promise for promoting active student lifestyles.Trial registrationProspero ID—CRD42021242170.

Barriers and enablers to blood culture sampling in Indonesia, Thailand and Viet Nam: a Theoretical Domains Framework-based survey

ObjectiveBlood culture (BC) sampling is recommended for all suspected sepsis patients prior to antibiotic administration. We examine barriers and enablers to BC sampling in three Southeast Asian countries.DesignA Theoretical Domains...

Physiotherapists’ barriers and facilitators to the implementation of a behaviour change-informed exercise intervention to promote the adoption of regular exercise practice in patients at risk of recurrence of low back pain: a qualitative study

BackgroundRecurrences of low back pain (LBP) are frequent and associated with high levels of disability and medical costs. Regular exercise practice may be an effective strategy to prevent recurrences of LBP, however, the promotion of this behaviour by physiotherapists seems to be challenging. This study aims to explore physiotherapists’ perceived barriers and facilitators to the implementation of a behaviour change-informed exercise intervention to promote the adoption of regular exercise practice by patients at risk of recurrence of low back pain.MethodsTwo focus groups with primary healthcare physiotherapists were conducted, based on a semi-structured interview schedule informed by the Behaviour Change Wheel, including the Capability, Opportunity, Motivation–Behaviour (COM-B) model and the Theoretical Domains Framework (TDF). All focus groups were held through videoconference, audio and video recorded and transcribed verbatim. A deductive content analysis, using a coding matrix based on the COM-B and TDF, was performed by two independent researchers. A third researcher was approached to settle disagreements.ResultsIn total, 14 physiotherapists participated in the focus groups. The analysis revealed a total of 13 barriers (4 COM-B components and 7 TDF domains) and 23 facilitators (5 COM-B and 13 TDF) to physiotherapists’ implementation of a behaviour change-informed exercise intervention. The most common barriers were the lack of skills and confidence to implement the proposed intervention. These were explained by the fact that it differs from the usual practice of most participants and requires the learning of new skills applied to their contexts. However, for those who had already implemented other similar interventions or whose rationale is aligned with the new intervention, there seemed to exist more positive determinants, such as potential benefits for physiotherapists and the profession, improvement of quality of care and willingness to change clinical practice. For others who did not previously succeed in implementing these types of interventions, more context-related barriers were mentioned, such as lack of time to implement the intervention, schedule incompatibilities and lack of material and human resources.ConclusionsThis study identified modifiable barriers and facilitators to physiotherapists’ implementation of a behaviour change-informed exercise intervention for patients at risk of recurrence of LBP in primary healthcare. The findings of this study will allow the systematic and theory-based development of a behaviour change-informed training programme, aimed at physiotherapists and supporting the successful implementation of the exercise intervention.

Barriers and Facilitators to Aerobic Exercise Testing Practices of Physiotherapists in In-Patient Stroke Rehabilitation Settings Across Canada: A Theory-Informed Web-Based Survey

Background and Purpose: Stroke best practice guidelines recommend aerobic exercise (AEx) testing once patients post-stroke are medically stable and before initiating AEx training. This study describes current AEx testing practice of physiotherapists (PTs) in in-patient stroke rehabilitation (SR) and the barriers and facilitators to this practice. Methods: We conducted a cross-sectional web-based survey of registered PTs working in Canadian in-patient SR settings, guided by the Theoretical Domains Framework (TDF). Results: Fifteen of 37 (41%) participants reported conducting AEx testing with people post-stroke. A field test (92%) involving walking was the most commonly used test type. Barriers and facilitators to AEx testing practice from all 14 TDF domains were endorsed. While 73% ( n = 19/26) participants recognized that AEx testing supports therapy goals, over 60% reported lacking maximal and submaximal AEx testing knowledge and skills, and 58% did not perceive AEx testing to be an organizational priority due to the focus on function and mobility during in-patient SR. Discussion and Conclusion: Less than half of participants performed AEx testing despite recognizing its value for people post-stroke. Predominantly, practitioner- and organisation-related factors influenced participants’ use of AEx testing in in-patient SR. An understanding of how PTs can navigate the complex barriers to AEx testing is needed.

Enablers and Barriers to Hearing aid Use in People Living With Dementia.

Hearing loss is highly prevalent in dementia; however, people with dementia are less likely to use hearing aids consistently than people with intact cognition are. This qualitative study is the first of its kind to explore factors that influence hearing aid use from the perspective of community-living people with mild to moderate dementia and their care partners. Eleven UK-based dyads from the European SENSE-Cog Randomized Controlled Trial of a sensory intervention for people with dementia completed semi-structured interviews based on the Theoretical Domains Framework (TDF). Our findings suggest that the TDF domains environmental context and resources, behavioral regulation, reinforcement, and social influences are of greatest relevance to hearing aid use in dementia. Within these domains, we identified a range of factors that may influence the target behavior of hearing aid use. The findings suggest that adoption of multifaceted, flexible intervention approaches may support hearing aid use in dementia.

A COM-B and Theoretical Domains Framework Mapping of the Barriers and Facilitators to Effective Communication and Help-Seeking Among People With, or Seeking a Diagnosis Of, Endometriosis

Endometriosis is a chronic condition in which tissue resembling the endometrium grows outside the womb, causing severe chronic pain. People with endometriosis report difficulty in help-seeking and communicating with healthcare professionals, contributing to diagnosis delays and ineffective management. The present study aimed to identify barriers and facilitators to effective communication using the Theoretical Domains Framework (TDF) and COM-B model to inform behavior change intervention development. This study was a qualitative semi-structured interview and open-ended survey design. Thematic Analysis was utilized to identify barriers and facilitators to effective communication which were mapped to the TDF and COM-B model. Four women aged 25 to 44 with a formal diagnosis of endometriosis participated in interviews. Thirty-three participants, aged 20–48 years, participated in the online survey, 21 of whom had a diagnosis of endometriosis (12 were currently seeking diagnosis). Five COM-B domains were identified: reflective motivation, social and physical opportunity, physical and psychological capability. Ten TDF domains were reflected in concerns surrounding dismissal, disempowerment, social norms, beliefs about consequences, cognitive resources, reinforcement, and environmental context and resources, among others. This is the first study to identify barriers and facilitators of effective communication and help-seeking in light of established behavioral change theory and frameworks for comprehensive intervention design. This provides a comprehensive explanation of challenges in help-seeking for endometriosis and represents the first step in the development of complex interventions to improve help-seeking and communication for people with endometriosis. Interventions targeting salient barriers will have greater potential to change behavior and improve outcomes.

"I want to be there. I have to be there.": Parents' perceived barriers and facilitators to bedside presence in the pediatric intensive care unit.

Parental presence at the bedside during a stressful pediatric intensive care unit (PICU) admission may improve child comfort, reduce parental anxiety, and enable family engagement. We performed this study to identify factors that parents perceive impact their capability, opportunity, and motivation to be at the bedside in PICU. We conducted a qualitative descriptive study using semi-structured interviews based on the Theoretical Domains Framework (TDF). We included parents of children admitted to the PICU for at least 24 h at IWK Health in Nova Scotia, Canada. Interviews were coded independently by two researchers using a directed content approach based on the TDF. We generated themes and subthemes, with the subthemes identified as factors impacting parental presence, and assigned TDF domains to each of the subthemes. Fourteen primary caregivers (8 mother figures, 6 father figures) participated in 11 interviews. The factors associated with parental presence were captured by 6 themes: Understanding the Medicalized Child; Maintaining the Parent Role; Life Beyond the Hospital; Parental Intrinsic Responses and Coping; Support Structures; and The PICU Environment. Fifty-two barriers and enablers were identified within 13 TDF domains; 10 TDF domains were determined to be relevant to parental presence, which may be used to guide design of future interventions. Participants emphasized the importance of self-care to enable them to remain physically at their child's bedside and to be engaged in their care. Parents perceive multiple factors within 6 themes act as barriers or enablers to presence with their critically ill child in the PICU. Guided by relevant TDF domains, interventions may be designed to optimize presence, particularly engaged presence, which may improve health-related outcomes of children and their parents.