Background
Regular physical activity has a positive impact on both mental and physical health. Yet, almost half of adults in high income countries are insufficiently physically active [
1]. Physical inactivity is a public health threat and one of the ten most significant risks factors for loss of disability adjusted life years worldwide [
2].
Healthcare services have a unique role in promoting health, as it reaches a large part of the population, including vulnerable groups which may otherwise be difficult to reach, such as the elderly, socio-economically weak and people on sick leave [
3]. Guidelines in Swedish healthcare regarding methods for preventing diseases caused by unhealthy lifestyle behaviours, such as tobacco use, harmful use of alcohol, physical inactivity and unhealthy diet, were launched by the Swedish National Board of Health and Welfare in 2011 [
4]. These guidelines [
4] recommend that in regard to insufficient physical activity, healthcare should offer person-centred health promotion counselling, combined with written prescription of physical activity or monitoring of physical activity by pedometers, and also a follow-up of the prescribed physical activity.
The Swedish Physical Activity on Prescription (SPAP) was introduced in 2001, as a method for Swedish healthcare to promote physical activity both for the prevention and treatment of lifestyle related health disorders [
5]. The SPAP method consists of five core components: 1) person-centred health promotion consultation, 2) written prescription of physical activity summing an agreement between the patient and the health professional based on the expressed intentions and goals of the patient, and the knowledge and competence of the health professional, 3) a prescription guided by evidence-based knowledge on physical activity in the prevention and treatment of health conditions; i.e. in accordance with the recommendations in the handbook “Physical Activity in the Prevention and Treatment of Disease FYSS” [
6], 4) follow-up of the written prescription, and 5) collaboration between the healthcare service and physical activity organisers outside healthcare (e.g. sports clubs, fitness centres). It is also emphasised that the method should be tailored to local conditions in the healthcare organisation [
7,
8].
Studies have reported that prescriptions in line with SPAP increase physical activity level in patients in primary healthcare [
9,
10]. SPAP has also been shown to reduce sedentary time [
11], have a positive effect on health-related quality of life [
9,
12] and on risk factors for metabolic syndrome and cardiovascular diseases [
11,
13].
Despite scientific support for SPAP and its components, the use in healthcare services has been low [
4,
14]. Since the introduction, attempts have been made to facilitate implementation of SPAP in primary healthcare practice, mainly through information and the education of healthcare professionals. However, these attempts have not yielded a lasting effect on the usage of the method [
8]. There are few studies on how the components of SPAP are applied clinically, or on how to support implementation of SPAP in healthcare services [
15‐
17].
Implementation of new healthcare practices can be seen as a process of behavioural change that is affected by many actors and factors on different levels [
18]. Health promotion practices often take a longer time to implement in clinical practice as compared to, e.g. new technologies [
19,
20]. According to The Promoting Action on Research Implementation in Health Services framework (PARIHS), successful implementation is a function of the interaction of:
evidence, i.e. the degree of scientific support for the proposed change,
context, i.e. the environment in which the proposed change is to be implemented, and
facilitation, i.e. the manner in which the change is supported [
18,
21]. Factors of importance for successful implementation of a new method include the individual healthcare provider’s attitude to the method, and that it targets a perceived need by the users as well as general features, such as the organisational culture. The implementation strategy should involve a clearly structured method for the clinical work, and the application of the method should fit as part of regular procedures. If relevant and evidence-based methods are not applied in healthcare, it is important to identify the underlying mechanisms for non-application, in that appropriate strategies to support implementation can be developed [
20]. It would also be important to identify the personal and contextual barriers and facilitators for implementation of the SPAP method in healthcare, in order to gain better understanding of factors affecting the process. Thus, the aim of the study was to describe the views of health professionals on perceived facilitators, barriers and requirements for successful implementation of SPAP in primary healthcare.
Methods
Study design
This is a descriptive study using qualitative content analysis [
22] of interview data with both a deductive and inductive approach [
23].
Participants
We used a purposeful sampling approach to select stakeholders in SPAP in two regional healthcare organisations in Sweden. The participants consisted of ten people working in primary healthcare management (three managers of healthcare centres; two local SPAP coordinators; and two managers and three health promotion coordinators in the central administration of the healthcare organisations), and eight health professionals working in primary healthcare centres (three physicians, two registered nurses and three physiotherapists). In all, eighteen stakeholders were interviewed: five stakeholders at management level from each region plus five and three health professionals from each region respectively. The sampling was done to represent maximal variation in type of profession, management level, number of SPAP prescriptions at the primary healthcare centres and the size of the primary healthcare centres. By including the two regional healthcare organisations it was possible to illuminate differences with regard to the organisation of health promotion services, in that one organisation provided central guidelines, other materials and advisory support on SPAP to the healthcare staff to a much greater extent than the other organisation.
Ethical considerations
The study was approved by The Ethics Review Board at Uppsala University (EPN Uppsala No. 2014–198). Verbal and written information about the study were provided to the participants. Written consent for participation were obtained from the participants prior to the interviews.
Procedure
Individual interviews were undertaken during the autumn of 2014 according to a semi-structured interview protocol [
24]. The protocol contained open ended questions designed to respond to the research questions of the study: What factors in the organisational context facilitate or impede prescription of SPAP in patient consultations? What requirements are needed to facilitate increased prescription of SPAP? During the interview, the interviewer posed follow-up questions, restated and summarised information, and asked the participant to confirm the accuracy of the spoken data [
25]. English language copies of the two Interview Guides used to direct discussions are attached as a supplementary file (Additional file
1). The interviews lasted for 15–45 min and were carried out in a room at the participant’s place of work where only the participant and the interviewer were present and undisturbed by others. The second author conducted all of the interviews of participants in management positions, and a research assistant (a physiotherapist working in primary healthcare and well acquainted with the SPAP method), conducted all of the interviews with the health professionals. The interviews were audio-recorded and transcribed verbatim directly after each interview by a research assistant.
Data analysis
The interview data was analysed using qualitative content analysis [
22], and undertaken in two steps [
23]. First, the interviews with the participants working in healthcare management were analysed by an inductive approach. Second, the interviews with health professionals were analysed by a deductive approach based on the categorisation matrix created from the healthcare management interviews.
The first and the second author read the text files of the interviews as soon as they had been transcribed in order to gain an overview of the material, along with a sense of when the material was sufficiently saturated, i.e. when similar descriptions of attitudes and perceptions of facilitators and barriers to the use of SPAP recurred in the interviews.
The first and the second author also performed the initial data analysis by reading the text and identifying meaning units, i.e. specific units of text consisting of a single word, a few words, or a few sentences relating to the research questions. Meaning units were condensed and coded. Codes were then discussed and grouped together into higher order subcategories and categories. In order to minimise bias, a dialogue was ongoing between the two authors, which facilitated openness to the text with its meaning units, codes, subcategories and categories. In order to validate the interpretation, all authors read the text files, discussed the coding and reviewed the preliminary interpretation. All authors participated in the analysis by discussing and revising the interpretation until consensus was obtained. Table
1 provides examples of the analytic coding process by which meaning units, codes, subcategories and categories were formed.
Table 1
Subcategories and examples of codes and meaning units in the category “Need for central supporting structures”
Need for central supporting structures | Establish a centralised function within the healthcare organisation for coordination and development of SPAP | Support (by education, written material) from central health promotion unit |
...someone who lectured and talked about the method at the healthcare centres, if there were experts who could come out to us.
|
...you need to get more information out, to us here at the primary healthcare centre, on how to use this method…
|
Support (by inspiration, coaching and regular updates) from central health promotion unit |
...some sort of events or something that happens all the time, so that you could get inspiration...
|
...we used to get to meet the central health promotion coordinator once or twice a year for updates on our prescriptions and for some inspiration
|
Expand cooperation with external physical activity organisers | Central support for organised cooperation outside healthcare | ...someone who finds clever ways when working with other organisations [i.e. outside healthcare] and referring patients. |
...someone, like a central coordinator or something, so that updating [of contact list to activity organisers] is done all the time |
Open coding using an inductive approach was used for the data generated by the interviews with those working in healthcare management positions. After coding, the data from the interviews with health professionals was grouped into the pre-defined subcategories and categories in the structured categorisation matrix created from the inductive analysis. When using this matrix we selected the aspects (meaning units) that fitted the categorisation frame, but were still open to that aspects which did not fit the categorisation could be used to create new categories to be added to the matrix.
Discussion
This study disclosed key requirements for the implementation of the SPAP method in primary healthcare, in particular, the need for knowledge of the method and organisational support. An important facilitator revealed was that all health professionals undisputedly acknowledged the importance of promoting physical activity. Identified barriers for implementation were insufficient knowledge among health professionals of the core components in SPAP and lack of organisational support, including accessibility of policy documents and clinical guidelines, explicit management endorsement of SPAP and lack of resources, primarily time.
All participants had a positive attitude towards health promotion and agreed that it was important for healthcare to address health behaviours and support physical activity in patient consultations. However, only a few used the SPAP method for that purpose. This is not surprising since the basic knowledge of the method was lacking. It was an interesting finding that most participants revealed a lack of knowledge of the SPAP method: i.e. its components and theoretical underpinnings, and how to apply it. The health professionals also reported that they lacked time to use SPAP, in part referring to that the method was time consuming and due to contextual barriers, such as not having computer and printer in the same room where they met the patients. But in our interpretation this might be another way of expressing a lack of understanding of the rationale and benefits of the method and of how the core components of SPAP are intended to be applied. However, it was also clear that the health professionals felt that they did not have enough organisational support for providing SPAP, neither from policy documents and clinical guidelines, nor from management.
Our study is helpful in that only a few studies have investigated how the core components in SPAP are used clinically and how the implementation of SPAP in healthcare can be facilitated [
15‐
17]. The findings in our study suggest that there is limited knowledge regarding the components of the SPAP method. Many of the interviewed health professionals, who are the potential users of the method, had little knowledge of the other components, apart from the written prescription. These findings are similar to the results of an interview study on patients who had been prescribed SPAP by physicians in primary healthcare [
26]. Those patients perceived that they had been given very little information about SPAP, they had not been listened to and actively involved in the prescription and they were uncertain about the distinction between SPAP and physiotherapy. This corresponds well to our finding that very few of the informants stressed the importance of the person-centred health promotion consultation, i.e. component 1, prior to prescription. The widespread misconception of the rationale and components of SPAP is further shown in the criticism made by a task force in The Swedish College of General Practice, claiming that SPAP is an unnecessary and potentially harmful method that should not be used in healthcare [
27]. These authors assert that “SPAP is a patriarchal method” implying that the focus is on the written prescription and that it is issued by the health professional based solely on professional competence, ignoring the patient’s involvement [
27]. This criticism was based on results from other methods for physical activity promotion (i.e. exercise referral in the UK [
3]), and thereby fails to recognise that the SPAP method emphasises the importance of the person-centred health promotion consultation. Nevertheless, it has had impact on practitioners as revealed in our interviews.
We suggest that understanding of the theoretical underpinnings for the components in the SPAP method is important for the motivation to apply the method. Thus, education in the SPAP method should include knowledge about behaviour learning principles, social cognitive theory [
28] and communication techniques that promote behaviour change, such as Motivational Interviewing [
29]. This kind of knowledge generates proficiency in addressing cognitive and behavioural risk factors for problematic health outcomes [
30], and for supporting patients in goal-setting techniques and self-monitoring of health behaviours in relation to physical activity [
31,
32].
Another important finding was that although central policy documents in both healthcare organisations stated that applying disease preventive methods is a prioritised and mandatory work task in healthcare services, several of the participants expressed that there were not enough local supporting structures, such as locally tailored routines and local SPAP coordinators. This was especially prominent in the healthcare organisation that had a central health promotion unit that was less known among the health professionals. More surprisingly, in the other healthcare organisation that had an active central health promotion unit, the participants still perceived that they had insufficient locally tailored routines. The expressed need for firm and substantial central support could proposedly be provided through lectures presenting content of new/updated policies and guidelines, regular alerts on updates, updating lists of physical activity organisers, and guidance in how to convert central policies and guidelines into locally tailored routines. Having elaborated central guidelines into locally tailored routines at each primary healthcare centre has been suggested as important for successful implementation [
14].
Specifically, undertaking follow-up of written physical activity prescriptions was perceived difficult to manage by the health professionals due to lack of time and resources. Providing follow-up of health behaviours, such as health-promoting physical activity, has been shown to be important for adherence to the prescription and for success in health behaviour change, and thus an important component in the SPAP method [
17]. Some of the informants expressed the need for a local SPAP coordination function with time to undertake follow-up of prescriptions. This corresponds in some part to the results of another Swedish study [
15,
16] on general practitioners, showing that their willingness to prescribe SPAP increased if they could cooperate with a physiotherapist in the prescription process. In that study, the physicians stated that they were happy to initiate the SPAP process, but wished that the physiotherapist would complete the motivational interview and agreement with the patient regarding the type of activity, duration and intensity, and also carry out the prescription follow-up. According to Persson et al. [
15,
16], the physicians felt that prescribing SPAP was neither part of their professional role, nor did they have time to prescribe and carry out follow-up of the prescription. In our study, the wish to cooperate with a physiotherapist was expressed by some participants, but not all. In contrast, some of the participants emphasised that all health professionals had a shared responsibility to advocate health promotion.
By using a qualitative method for data collection, a broad range of requirements for facilitating implementation of the SPAP method was revealed that would otherwise have been difficult to identify through a quantitative design. A purposeful sampling strategy was used in order to obtain a rich and broad material presenting maximum variation [
33]. The sample was selected to include as many of the factors in participants’ characteristics and settings, which might affect variability and have relevance to the conceptualisation of the phenomenon, as possible. However, there is a risk of selection bias or an incomplete sample by such a method. In this study credibility and transferability was enhanced by using a sample of participants representing diversity of professional background, different levels in the healthcare organisations and representing two healthcare organisations with slightly different contextual conditions. Still, the small sample of participants in our study is a limitation to transferability of the result. We only interviewed two or three participants from each category of health profession. It is possible that the participants were not representative of all people with the same professional background. Some of the study findings are in correspondence with other Swedish studies, thus indicating that the result might be generalised to other parts of the Swedish primary healthcare, not solely the two healthcare organisations studied here. We only interviewed stakeholders within the healthcare organisations, and thus the perspective of the patient was not included. To reduce the risk of bias in data collection and analysis, respondent validation (member checking) was undertaken during the interviews [
25]. To increase trustworthiness in the interpretation of data, all researchers read the text files of the interviews and participated in discussing the coding, categorisation and interpretation of data [
24,
25].
Acknowledgements
The authors thank Anna Duvander, RPT, Dalarna County Council, for her valuable contribution to data acquisition by undertaking half of the interviews with primary healthcare staff. The authors are grateful for the contribution of health professionals and management in the two Swedish regions: Dalarna County Council and Region Gävleborg.