Promotion of physical activity in older adults: facilitators and barriers experienced by healthcare personnel in the context of reablement

In Norway, where this study was conducted, reablement is delivered free to participants through publicly funded healthcare services. Municipalities are obligated to deliver care that meets national laws and overall policy. However, they have the authority to organize and deliver the services in whatever way they choose. Reablement has been rapidly and extensively implemented in Norway over the last decade, though with significant differences in its organization and delivery [21, 27]. Two main organizational models have been identified, in which reablement is either provided as an integrated part of home care services or through a specialized reablement team [27]. The implementation of reablement has been supported by national healthcare policies [27], and it is suggested as one of several strategies within a national quality reform currently being implemented in Norwegian municipalities to provide services that help older adults maintain their independence in daily life and encourage a safe and active older age [28].

A purposive sampling strategy was used based on principles of variation sampling, in which the intention is to reach variation in small samples based on pre-defined selection criteria [29]. To gain variation at the municipal level, we selected four municipalities that provided reablement, and that differed in size and organizational model because this may involve different premises for practice [21, 27]. To gain variation at the HCPs’ level, we included HCPs (n = 16) with diverse professional backgrounds who were central in delivering reablement in their respective municipality. The HCPs had to have at least 1 year of experience with reablement. By including this heterogeneity in the study sample, we aimed to gain knowledge of central factors that cut across the existing variation and also captured diverging factors influencing how HCPs promoted PA within their context.

Eligible municipalities were selected, and the leaders of the reablement teams in these municipalities were initially asked for permission to contact potential candidates on their team. The leaders were encouraged to suggest potential candidates who were reflective of their practice, and represented diverse professional groups. Each potential candidate was contacted in person by phone or e-mail, given verbal and written participant information, and signed a consent form before any data collection. All the reablement leaders contacted were positive about participation, and all the HCPs who were recommended and contacted agreed to participate.

The research team developed a semi-structured interview guide and discussed it with HCPs working with reablement in a municipality not included in the study (see online additional file 1). The interview guide served as a guide for conversational topics and direction throughout the interviews, but the question order was not followed strictly.

Each HCP participated in one interview. Each interview lasted 70–90 minutes and was conducted by the first author (HLM), who had no prior relationship with the HCPs. Before the interviews, the interviewer gave brief information about her professional background and the aim of the study. The interviews were undertaken as individual face-to-face interviews between May and October 2019 in a quiet office or meeting room at the participants’ workplace and were audio-recorded.

We used an inductive qualitative content analysis, informed by Erlingsson and Brysiewicz [30]. Interviews were transcribed verbatim and read several times, noting reflections and main impressions accordingly. Each transcript was then systematically searched for units of text about facilitators and barriers that influence how HCPs promote PA and given codes using NVivo software©. The text units were condensed and organized into categories. This initial stage of the analysis demonstrated great variability and complexity of different factors influencing how the HCPs promoted PA in reablement. To better structure the continued analysis, we divided the categories we had identified into a participant,- professional,- organizational,- and system level, inspired by the integrated care mechanisms framework by Valentijn et al. [22]. Followingly, we continued organizing and questioning the content and coherence between the categories, as well as clarifying facilitators and barriers within each category. An overview of the categories, organized within each level is illustrated in Fig. 1. This was an interpretative, non-linear process involving careful consideration of the consistency between parts of the data and the interpretations achieved through the analysis. The analysis was undertaken by one researcher (HLM) and was critically discussed among the research team to analyze the coherence of the findings and how the researchers’ preunderstandings influenced the analysis. After analyzing 16 interviews, we found the data to be sufficiently saturated for this study. We found that the HCPs reported factors within the same overall topics yet described variations in how these factors influenced their practice. This approach followed the principles of data saturation within a reflexive content/thematic analysis approach [31]. We used the questions raised in the checklist developed by Elo et al. [32] to critically reflect upon the trustworthiness of the study’s methodology. Quotes from the interviews are presented to exemplify the main findings. The quotes have been translated to English and edited slightly to improve grammar and flow, but their meaning and intent have not been altered.

Sixteen HCPs participated in this study, including four OTs, four PTs, four home care assistants, two RNs, and two HCPs with other health and/or social educational backgrounds (their particular education is not specified to avoid compromising their confidentiality). The HCPs’ median age was 46.5 (range 29–57), and two of them were male. On average, they had 19 years of professional experience (range 4–33) and 4 years of experience working with reablement (range 1–6 years). An overview of the characteristics of the participants is presented in Table 1.

The HCPs were employed in four different Norwegian municipalities varying in population (4000–200,000). Two of the municipalities had organized reablement as an integrated part of the home care services, in which OTs and PTs from the rehabilitation section collaborated with staff from the home care services. According to their shift schedules, the home care staff could either be a few selected HCPs from the home care services trained in reablement or any staff from the home care service. In the other two municipalities, reablement was delivered by specialized reablement teams involving HCPs employed on the team. One of these specialized teams consisted of a PT, an OT, and two home care assistants. The other specialized team consisted of only PTs and OTs and involved HCPs from the home care services when deemed appropriate. The duration of the reablement interventions in all municipalities was approximately 6 weeks, but if needed, these could increase. The frequency and duration of visits were variable between municipalities, ranging between 2 and 5 visits per week and 20–60 minutes per visit. General characteristics of reablement in each municipality are presented in Table 2.

The HCPs experienced several factors at a participant, professional, organizational, and system level that influenced how they promoted PA in the reablement context, as illustrated in Fig. 1. The degree to which these factors were experienced as facilitators or barriers differed between reablement settings and depended on the interrelationship between factors on different levels. An interdependent coherence between facilitators and barriers on all levels influenced how the HCPs recruited people who could benefit from being more physically active; targeted PA to the individual participants’ desires, needs, and progress; and facilitated continued long-term PA habits. Some facilitators and barriers experienced by the HCPs influenced their ability to promote PA as well as their reablement delivery in general.

A strength of this study is the purposeful sampling strategy used to ensure that we included HCPs from municipalities that differed from each other in the organization of reablement. This strategy enabled us to explore both similarities and differences in how the reablement context is experienced and how it influences HCPs’ practice across municipalities. Although the study findings relate to a Norwegian reablement setting, our study provides a potential frame of reference that can be used to explore contextual factors in other reablement settings, both nationally and internationally.

Also, we consider the interview guide and the semi-structured interview approach useful for capturing both the HCPs’ experiences with reablement in general and their experiences with PA promotion specifically. This approach enabled us to combine these experiences to gain a broad conceptual understanding of the facilitators and barriers in the reablement context, as seen through a micro, meso, and macro perspective of healthcare. A weakness of this study is that our recruitment strategy may have led to the inclusion of HCPs who are particularly enthusiastic about reablement, and we may not have addressed important facilitators and barriers experienced by HCPs who do not share this enthusiasm.

These findings illustrate how different factors in an integrated healthcare system influence reablement delivery and can be a useful tool to further identify and evaluate factors that may influence reablement delivery in different contextual settings. This can inform clinicians, leaders, and politicians of the potentially successful factors and pitfalls that may enable or hinder successful implementation and delivery of reablement and/or strategies for promoting PA among older adults relative to the particular context.

The findings contribute to an increased understanding of factors influencing evidence-based healthcare in reablement from the HCPs’ perspective. The findings contribute to a greater understanding of mechanisms influencing reablement delivery in different contexts and demonstrate how the context withholds important mechanisms influencing how PA is promoted in reablement. There is a need to further explore how HCPs utilize and negotiate their professional competencies and perspectives within different reablement settings and how this influences how PA is promoted. Such different contextual mechanisms are important to acknowledge in future research of reablement and studies targeting PA promotion in older adults to develop evidence-based and person-centered real-life practice.