Background
Osteoarthritis is a leading cause of pain and reduced function and quality of life [
1]. In the United Kingdom (UK), OA is a burden on health services and the greatest cause of individual level disability in people aged 45 years or older, with approximately 2 million general practitioner (GP) visits each year related to OA symptoms [
2]. The large synovial joints of the lower-limb (hip and knee) are the most common cause of OA related pain, accounting for approximately 70% of symptoms [
3]. As there is currently no cure for OA [
2], and with increased life expectancy [
4], it is likely that greater numbers of patients with lower-limb OA will be required to self-manage their symptoms to reduce the load on healthcare systems in the coming years.
Promoting physical activity is a key non-pharmacological strategy that healthcare guidelines recommend to aid patients with lower-limb OA to manage their symptoms [
1,
2,
5,
6]. However, the majority of patients with lower-limb OA are less active than asymptomatic populations [
7], and healthcare PA interventions are generally only effective at reducing short-term (≤ 3 months post baseline) [
8] symptoms, with pain and loss of function returning after about 6 months [
9]. This is likely associated with a gradual reduction in patient adherence to prescribed PA after discharge, when approximately 90% of patients with lower-limb OA do not maintain their PA [
10].
People undergo several ‘phases’ of behaviour change when integrating new behaviours into their lifestyle [
11]. The most important phases are
‘adoption’ [
12,
13], which occurs while people are receiving treatment from a health professional, and
‘maintenance’ [
14] which would be ongoing post-discharge and occurs after 6 months of behavioural practice. While adoption and maintenance have several overlapping influences, they also possess unique determinants [
11,
15,
16]. Therefore, a healthcare intervention needs to incorporate specific behaviour change techniques (BCTs) to match these phases in the behaviour change process to optimise PA adherence.
Physiotherapists are the primary healthcare provider of non-pharmacological treatments for patients with lower-limb OA [
17]. As such, they are in an optimal position to promote PA adherence [
18]. However, physiotherapists and patients with lower-limb OA do not necessarily agree with the most effective BCTs to promote PA adherence [
19]. Furthermore, patients with lower-limb OA believe they require more support and can perceive prescribed PA (e.g. exercise) as unsafe [
20]. Physiotherapists also perceive they do not have sufficient understanding of BCTs to deliver them consistently in practice [
21].
The Medical Research Council (MRC) advocates that interventions should be informed by behaviour change theory [
22] to enable a greater understanding of the assumed intervention mediators (e.g. self-efficacy) effects on the target behaviour to enable refinement for future testing, and therefore, greater clinical effectiveness over time [
23]. The Theoretical Domains Framework (TDF) is a validated framework which synthesises constructs from 33 theories of behaviour change into 14 overarching domains [
24,
25]. By mapping barriers and facilitators to specific domains, the TDF can be used to identify key determinants of behaviour change [
26] and important BCTs to develop theoretically informed interventions [
27,
28].
Qualitative methods are utilised to provide an in-depth understanding of patients experiences and identify barriers and facilitators to treatment [
29]. Although previous qualitative studies [
30‐
38] have determined barriers and facilitators to PA for patients with lower-limb OA, only one study has considered stages of behaviour change in their analysis [
39]. Hammer et al. [
39] found that patient self-efficacy and severity of symptoms were highly influential on PA maintenance. However due to their long-term focus, it was problematic to identify similarities or differences in determinants that occurred while under treatment (related to adoption) or post-discharge (related to maintenance) and their results were not utilised to develop a behaviour change intervention. Currently there are no theoretically informed interventions that incorporate BCTs that target the overlapping and unique features of PA adherence during the adoption
and maintenance phases. Therefore, this study aimed to gain an in-depth understanding of the overlapping and unique barriers and facilitators to physiotherapist prescribed PA that patients with lower-limb OA experience during treatment and post-discharge to develop a theoretically informed physiotherapy intervention.
Objectives
1)
To explore patients’ in-depth experiences of barriers and facilitators to physiotherapist prescribed PA within sessions that effect adherence while receiving treatment and post-discharge.
2)
To use the barriers and facilitators to identify themes/subthemes that influence patient’s adherence to prescribed PA during treatment and post-discharge.
3)
To map themes/subthemes to the TDF to identify key domains that effect adherence to PA during treatment and post-discharge.
4)
To identify appropriate BCTs from the TDF domains to propose a theoretically informed intervention aimed at optimising PA adherence.
Discussion
This is the first qualitative study to gain in-depth perspectives of the barriers and facilitators to physiotherapist prescribed PA during the treatment and post-discharge phases in patients with lower-limb OA. Inductive thematic analysis synthesised barriers and facilitators and themes and subthemes were collated into an a priori deductive framework which included three over-arching groupings: personal factors; treatment factors and; post-discharge factors. Subthemes were mapped to the TDF and results synthesised to outline the key domains to target for each theme. Thirteen TDF domains were identified and 26 BCTs were included in the proposed intervention, which represents the first theoretically informed physiotherapy intervention to target adherence to prescribed PA during treatment and post-discharge.
Personal factors
Personal factors that influenced participants perceptions of PA adherence were consistent with previous literature, specifically: motivation [
30,
33,
67], confidence [
30,
34,
35,
39,
68], mindset [
30,
34,
35,
39,
68] and experiences of arthritic symptoms [
33,
34,
39] and/or PA [
30,
34,
39]. Themes relating to personal factors were highly interactive and participants could be categorised into two broad profiles;
-
Those with higher levels of arthritic symptoms and/or decreased physical capabilities, or who experienced symptoms as a result of PA reported less confidence, motivation and/or a negative mindset reported difficulty adopting and/or maintaining PA behaviours and required ongoing practical and social support [
30].
-
Participants who had internalised PA behaviours [
16] or had high levels of social support reported feeling greater confidence, motivation and/or a positive mindset to adopt and maintain their PA post-discharge without additional need of support [
30].
The TDF domain ‘
Beliefs about Capabilities’ was influential for all personal factor themes. This domain includes constructs such as of ‘self-confidence’, ‘empowerment’, ‘perceived competence’, and ‘perceived behavioural control’. These constructs relate closely with participant confidence, mindset, and the theoretical cognition of self-efficacy [
69] which is a salient correlate of overall PA behaviours in patients with lower-limb OA [
39]. Participants discussed that positive PA experiences increased their confidence and generated a positive mindset, which facilitated motivation to engage with prescribed PA. Therefore, self-efficacy may act as an antecedent to motivation in the behaviour change process [
15] and BCTs that targeted the ‘
beliefs about capabilities’ construct (e.g.
instruction in how to perform the behaviour and
demonstration of the behaviour) were introduced early in the proposed intervention with several reoccurring.
Treatment factors
Forming a PA routine was the key mechanism to promote PA behaviours during treatment. Participants felt that physiotherapists could optimise their routine by instructing prescribed PA and enabling participants’ to practice/rehearse within sessions [
31,
32,
35,
36,
39,
68], slowly increasing PA in a graded manner, and providing feedback about PA or its associated outcomes (e.g. weight loss). Participants suggested that providing a demonstration of the behaviour (e.g. exercise sheet or video) and/or integrating self-monitoring of PA (e.g. pedometers or exercise diaries) into programmes would help regulate PA outside of the clinic during the treatment phase [
70]. Interestingly, participants linked these BCTs to promoting confidence and purposeful PA. However, they are underutilised in clinical practice [
70,
71] suggesting that physiotherapists may not be effective at utilising strategies which encourage PA adherence [
72]. Therefore, these BCTs were introduced in sessions to and reinforced in sessions three-four to facilitate behavioural adoption and routine formation respectively.
The beneficial effects of a positive patient-physiotherapist relationship are in line with previous studies, as participants commented that encouragement [
73], reassurance [
36], and developing a strong personal connection enhanced adherence to PA [
30,
74]. The proposed intervention therefore, utilises the reoccurring BCTs
social support (unspecified) and
(practical) respectively. Participants discussed how patient-centred treatment that involved collaboratively generated PA goals, led to feelings of empowerment and enhanced motivation to engage with PA [
31,
75]. The use of a collaborative approach is associated with advanced clinical reasoning and expert physiotherapist practice [
76]. Moreover, goal setting techniques with recurring review, were identified as important BCTs to promote PA adherence by patients with lower-limb OA [
19], and were included in the adoption phase of the proposed intervention.
Post-discharge factors
Several participants believed their physiotherapist could provide additional support post-discharge, as they perceived negative reactions from family/friends or peer PA groups [
30,
38] due to their reduced physical capacity. As intervention time is limited for physiotherapists, it would be beneficial if community resources for post-discharge PA provision were integrated with the physiotherapy provider [
34]. In line with previous studies, participants discussed that any post-discharge PA group needed to be exclusive to individuals of similar physical abilities [
32,
34,
36,
38,
39,
68] and diagnosis to enhance relatedness [
32,
36] and reduce feelings of anxiety or embarrassment [
32,
39,
68]. Therefore, the proposed intervention incorporated BCTs relating to
problem solving, and an indepth discussion on
how to structure the social environment during the maintenance phase [
28,
64,
65]. Community facilities primarily target those with decreased physical ability and lower income and need to be highly accessible [
30,
31] and at minimal cost [
19,
21]. However, particpants discussed that they found access to services highly problematic. Therefore, the proposed intervention included BCTs that alter the home environment, in order (to prompt routine formation and maintenance post discharge (e.g. using prompts and cues, or leaving Theraband in a prominent place to act as a reminder to their PA).
Reflections on TDF mapping and BCT coding
With the exception of the motivation theme, TDF mapping was intuitive and consistent with all discussion points clarified by the two researchers. Motivation has a multi-faceted influence on PA adherence [
30,
33,
67] that may change at different parts of the behaviour change process [
16]. This is perhaps reflected in the refined TDF [
28] which separated the original ‘goals and motivation’ domain [
27] into the distinct ‘goals’ (preferred outcome), and intentions (determination to act in a certain way). While it is acknowledged that motivation is a distinct mechanism or process of action in current research [
64,
65] further clarification of its definition within the TDF domains would likely increase consistency during mapping. These difficulties may also be linked to the topic guide design which was not informed by the TDF domains.
The TDF domains ‘environmental context and resources’ and ‘social influences’ were highly influential across both treatment and post-discharge phases. While the separation of themes into the personal factors, and treatment and post-discharge phases enabled some clarity of sequencing of BCTs, there was considerable overlap of domains across groupings. This suggests that behavioural adoption and maintenance have both unique and similar determinants.
Although the constructed matrix provided a useful tool, several BCTs did not overlap between studies and further work to establish agreement of the coding of BCTS from behavioural domains and mechanisms of action is required.
Strengths and limitations
Strengths include the transparent methodology [
77] to identify barriers and facilitators of PA adherence, which incorporated a valid and reliable framework to map them to determinants of behaviour change [
24], and an extensively utilised strategy of identifying BCTs [
28]. These strengths may enhance the interventions effectiveness at optimising adherence to PA. The study design facilitated an in-depth understanding of participant views and incorporating patient and public involvement further aided participants perspectives to be integrated during the intervention’s initial development.
A key limitation is that all participants were familiar with the person who recruited them, which may have influenced the findings. Furthermore, all participants were fluent English speakers of White British descent. While this reflected the hospital demographics, findings may not be generalisable beyond this population. In addition, participants recall PA levels were higher than those typically reported for patients with lower-limb OA [
7]. Although the sample may have included only active participants, inconsistent and over-reporting of PA levels with patient reported methods of data collection is widely outlined in the literature [
78], and perhaps strengthens the need for validated measures of objective PA in patients with lower-limb OA.
The theoretically informed physiotherapy intervention represents the initial proposal only. Prior to implementation, further data is required on the intervention’s feasibility to other stakeholders to clarify points on BCT mode of delivery, session lengths and frequency, and training needs of physiotherapists. Therefore, the feasibility and acceptability of delivering the intervention will now be tested in focus groups of physiotherapists working clinically prior to a phase two feasibility study.
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