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Physical inactivity is a leading risk factor for many health conditions, including cardiovascular disease, diabetes, and cancer; therefore, increasing physical activity (PA) is a public health priority. Health care professionals (HCPs) in primary care are pivotal in addressing physical inactivity; however, few HCPs provide PA advice to patients. There can be obstacles to delivering PA advice, including lack of time, confidence, or knowledge. Digital technology has the potential to overcome obstacles and facilitate delivering PA advice. However, it is unknown if and how digital tools are used to deliver PA advice in primary care consultations and what factors influence their use.
We aimed to understand the use of digital tools to support primary care consultations and to identify the barriers to and facilitators of using these systems.
Overall, 25 semistructured interviews were conducted with primary care HCPs. Professionals were sampled based on profession (general practitioners, practice nurses, and health care assistants), prevalence of long-term conditions within their practice area, and rural-urban classification. The data were analyzed thematically to identify the influences on the use of digital tools. Themes were categorized using the COM-B (capability, opportunity, and motivation—behavior) model and the Theoretical Domains Framework to identify the barriers to and facilitators of using digital tools to support the delivery of PA advice in primary care consultations.
The identified themes fell within 8 domains of the Theoretical Domains Framework. The most prominent influence (barrier or facilitator) within psychological capability was
A variety of influences were identified on the use of digital tools to support primary care consultations. These findings provide a foundation for designing a digital tool addressing barriers and leverages the facilitators to support PA advice provision within primary care to elicit patient behavior change and increase PA.
Physical inactivity is a leading cause of death and noncommunicable disease worldwide [
Therefore, identifying effective methods to increase PA in the population is of great importance. One approach is to provide PA advice to patients in primary care. As a trusted source of health-related information that frequently interacts with large proportions of the population, health care professionals (HCPs) within primary care have pivotal roles in encouraging greater PA [
Delivering brief PA advice in primary care has been shown to be cost-effective [
Establishing the routine delivery of PA advice in primary care requires overcoming such obstacles. A promising avenue is the use of digital tools, which may provide opportunities to facilitate the delivery of PA advice in primary care. These can include electronic tools that are integrated within clinical information technology systems in primary care or stand-alone technology that can help facilitate and signpost patients to various resources. The World Health Organization has highlighted the importance of using innovative digital technologies to promote PA and reduce sedentary behavior in its Global Action Plan on Physical Activity [
Digital tools have previously been used to deliver PA advice in primary care [
To determine the value of digital tools to support the delivery of PA advice and how to optimize their development and integration, it is important to fully understand the existing challenges of delivering PA advice, the influence on using digital tools, the required characteristics of digital tools, and the opportunities to incorporate digital tools into existing practice. However, there is a paucity of evidence surrounding the obstacles facing the use of digital tools to deliver PA advice. Studies rarely use a behavioral framework to systematically identify barriers and facilitators or instead focus on patient perspectives [
Systematic approaches to investigating the factors that influence health-related behaviors and professional practices can be facilitated using behavioral science tools. The capability, opportunity, and motivation—behavior (COM-B) system is a model of behavior change that helps to understand the influences on performance of a behavior [
We aimed to understand the use of digital tools to support primary care consultations and to identify the barriers to and facilitators of using these systems to deliver PA advice.
The specific objectives were (1) to gain insights into the use of digital tools within primary care settings to understand the influences on their use to deliver PA advice and (2) to systematically map the influences of using COM-B and TDF to understand the barriers to and facilitators of using digital tools within primary care to deliver PA advice.
This was an exploratory qualitative study drawing on interviews with HCPs in primary care.
A sample of HCPs was recruited purposively (by a third-party recruiter) based on profession (GPs, practice nurses, and health care assistants [HCAs]), prevalence of long-term conditions within the area (in particular, obesity, depression, hypertension, coronary heart disease, and diabetes), and rural-urban classification. During recruitment, HCPs were also screened to ensure a range of experience levels (based on the length of time working in primary care, self-reported levels of delivering PA advice, and self-reported digital skills). Data collection ceased once saturation of themes was reached, resulting in a total of 25 interviews being completed, transcribed, and coded.
To be included, study participants had to be a GP, nurse, or HCA; must have worked in general practice; must have worked in the United Kingdom health care system for a minimum of 1 year; must be an English speaker; and must be aged 18≥ years.
Semistructured interviews lasting 60 to 90 minutes were conducted via telephone in March and April 2020. This time frame coincided with the introduction of the first COVID-19 pandemic protocols in the United Kingdom, including the national lockdown on March 23, 2020. Hence, all study interviews were conducted via telephone. In line with ethical guidelines, written informed consent was obtained from the participants before commencing the interview. A topic guide based on COM-B [
During interviews, HCPs were asked a series of open-ended questions about their routines and working days; the systems and resources they use routinely to identify patients and to deliver and record advice; their capability, opportunity, and motivation to use these systems and resources effectively; any barriers to using these tools and resources; and suggested solutions and improvements to overcome them.
The topic guide included various prompts and follow-up questions to help elicit data relevant to the research question.
The interviews with the 25 HCPs were recorded on password-protected and encrypted machines to ensure data privacy and security. The recordings were uploaded to the encrypted, password protected Citrix platform to be transcribed verbatim by a third-party provider, and the original recordings were then deleted from the study team’s systems. The third-party provider removed any identifying information during the transcription and returned anonymized transcripts to the study team for data analysis.
The anonymized transcripts were imported into Microsoft Excel for analysis. Participant responses were broken down into constituent parts to analyze distinct thoughts and ideas independently. Content analysis, informed by the COM-B model, was used to analyze the data. One researcher (VM) read each of the 25 transcripts, extracted data relevant to the use of digital tools, and inputted the data into an Excel spreadsheet. In this study, we defined a “digital tool” as any use of information and communications technology to support HCPs in primary care to deliver PA advice. This definition was adopted from the World Health Organization’s definition of digital health [
In total, 165 comments from the participants relating to the use of digital tools were recorded. Another member of the research team inductively coded the data line by line using constant comparison techniques within and between codes to ensure that they accurately reflected the material. Codes were then examined for similarities and grouped inductively into themes regarding barriers to and facilitators of using digital tools to identify patients and to deliver and record PA advice. The themes that emerged from this process, that is, the ones that were identified as being important, were either articulated by multiple respondents (high frequency) or were articulated particularly clearly and forcefully (elaboration) or both. Once the data were coded as a barrier, facilitator, or both; they were deductively classified under the COM-B model [
Classifying data into COM-B components followed expert guidelines [
Ethical approval for this study was provided by the Public Health England Research Ethics and Governance Group (#NR0181). Participants provided written informed consent before taking part.
Participant characteristics are presented in
The barriers to and facilitators of using digital tools to deliver PA advice in primary care are presented in
Summary characteristics of participants recruited for interviews (n=25; 23 respondents for age and 24 respondents for location).
Characteristic | Participants | |
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General practitioner | 6 (24) |
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Practice nurse | 10 (40) |
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Health care assistant | 9 (36) |
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18-30 | 3 (13) |
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31-50 | 7 (30) |
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50+ | 13 (57) |
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1-10 years | 7 (28) |
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11-20 years | 9 (36) |
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20+ years | 9 (36) |
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Rural | 7 (29) |
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Suburban | 1 (4) |
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Urban | 16 (67) |
Important themes identified by participants during interviews on the barriers to and facilitators of using digital tools to deliver physical activity advice in primary care.
COM-Ba and Theoretical Domains Framework | Themes | ||
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Knowledge skills |
Having the skills to use digital tools Training in the use of digital tools |
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Physical skills |
Not reported as an influence |
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Environmental context and resources |
Availability Efficiency of digital tools Integration with existing systems Lack of access to digital tools Limited digital tools to prompt or support the provision of physical activity advice Simplicity and ease of use Technical support in the use of digital tools Time constraints |
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Social influences |
Digital tools reduce interpersonal communication Patient preferences |
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Beliefs about capabilities |
Confidence to use digital tools Perceptions about patient capabilities |
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Beliefs about consequences |
Beliefs about the usefulness of digital tools Beliefs related to data privacy and security Belief that digital tools are “the way forward” |
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Reinforcement emotions |
Familiarity Prompt behavior |
aCOM-B: capability, opportunity, and motivation—behavior [
I’m pretty good but EMIS is one of those things that there is always something more to learn really. You can learn the basics in quite a short period of time but I am still finding things that I think, God, if I’d have known that a few years ago, that would have saved me an awful lot of time.
There is no formal training by and large, other than you may get sent a document of how to do something. So we have relied upon one of our staff members who, for want of a better word, is like an IT manager who will take overall charge of these things and oversee their introduction and development, and disseminate that information as a practice and ensure that we’re all up to speed. So you need to have one person who has that as their responsibility and role within the practice.
Physical opportunity was the most frequently coded COM-B component (
I think it’d be quite useful really because with EMIS you can see people’s BMI and results and things like that, so it would be quite useful to have a prompt in the corner to say “encourage physical activity” or blah blah blah. It’s something that would be nice to have.”
It’s not on the diabetic template to ask about physical activity but it is on the NHS [Health Check] to check their physical activity.
We use templates [in our consultations]... If there is a patient with pre-diabetes, we... ask them: “would you like to go for the diabetes prevention programme?”... There’s no other template for us to use... On the system for the diabetes... we need to tell them... [to do] exercise—either walking or... going to the gym or any sort of exercise at home.
Another important barrier is
When you’re so busy and flat out, you don’t have sometimes that time to just sit back and reflect and think, well, is there another way I could be doing this more efficiently?
You have your clinics. You have your QOFs to do. You want to follow the NICE guidelines on every patient with a long-term condition. We have all of those responsibilities as well as the urgent on the day requests. Jiggling time is always a factor.
Relating to the themes of
It’s much easier. Much easier than sitting there writing things out. You can click. It gives you more time to do other things. It gives you more time with the patient. You’re not spending lots of time writing things out. You are more for the patient than you are writing things down.
I think sometimes in general practice the issue is we don’t have much time... So I think any way in which we can reduce the number of clicks, to put it simply, the better, and if this system was generated automatically, it flags it up, then that would be better than having to deal with all those issues and then think about doing something else on top as well. I think the easier to use, the quicker to use, the less steps involved the better really.
It would have to be something that would be compatible with the system that we’re using, and unfortunately I’m trying to get an ECG machine to be compatible with EMIS. So it’s all about compatibility and whether one talks to the other.
The final physical opportunity factor was
I suppose it’s what we’ve always used, we’ve never been told there’s anything else that can be used.
Barriers and facilitators related to social opportunities were less frequently discussed by the HCPs. However, there was an indication that some HCPs felt that
Part of me doesn’t mind but other times I think, Oh gosh I feel I’m looking at a computer screen rather than looking at a patient. I wasn’t trained to do that; I’m very old school as well because I trained back in the eighties so I don’t mind using it, I appreciate we have to move on with the times, but I don’t like it too much because I find that I’m watching the screen and making sure I’ve got everything that I need to fill on there without actually looking at the patient and just talking to them properly.
One of the clearest themes under reflective motivation to emerge from the data was that of
I mean I’m of the generation which is fairly IT savvy, so I feel quite confident.
Another theme that could be both a barrier and a facilitator for the use of digital tools was
We can even do things like video consultations now which I think we’ve had to embrace because of the current situation with COVID. I think it will change the way we practise ongoing because we can see the efficiencies of these. I think the model of general practice personally is going to change hugely after this because we can see we can do things safely and differently and more efficiently.
I don’t find the template is particularly useful... I don’t think it’s very useful in the information that it’s asking for. Then the options it gives you, do you want to refer them to the health trainer? Nearly everybody will say no to that because it’s too involved. It’s too time consuming.
A related theme to
The opportunities are there aren’t they, we’re moving forward and everything’s IT and it’s the way forward, for patients as well, apps and doing everything online and using phones.
Beliefs related to data privacy and security was another theme under reflective motivation that emerged from the data. This theme was both a barrier to and a facilitator of the use of digital tools, depending on the particular beliefs of each respondent. Some felt that digital tools improved security around patient data by reducing mistakes, whereas others said that the safety features required to ensure patient safety within digital tools could act as a barrier to their use:
They’re just safer, and they protect patient confidentiality, and they’re safer to use, things we can audit, trails, process it all, and obviously check if anything goes wrong, if there was a fax it may reject or get sent somewhere else if the number was wrong.
The final theme under reflective motivation was HCPs’
My dad, he needs everything explained manually and wouldn’t go near a computer; for him, I’d need to spend more time with him, to discuss a questionnaire I’d need to print it out and go through it with him, even phones.
A common facilitator of the use of digital tools in primary care within automatic motivation was that digital tools, specifically templates,
They’re optional, yes... I choose to use them, yes... It’s easier and I feel like it’s more thorough, and when it’s a busy day especially, it’s nice to just have that as a prompt.
I mean, sometimes when you first learn them, it is a bit daunting. You think, “oh,” and you’re looking through them, but once you’ve done it a few times, you get a rhythm... As I said, if you go through every box, you can’t go wrong.
This study aimed to investigate the use of digital tools to deliver PA advice. However, we found that digital tools for delivering PA advice were limited. Some templates include PA prompts, but no template focuses specifically on facilitating PA advice. Hence, we considered the use of digital tools in primary care; with the identification of themes based on high frequency, elaboration, or both. This study has implications for the development of digital interventions to facilitate the delivery of PA advice in primary care.
Barriers and facilitators to using digital tools to deliver PA advice identified in this study included
This qualitative study expands on previous findings on the barriers and facilitators to delivering PA advice in primary care [
The mixed views regarding the usability and utility of digital tools emerging from this study build on previous findings for eHealth interventions to deliver PA advice. Similarly, some HCPs find eHealth interventions useful and easy to use, but others perceive eHealth interventions to be time consuming or ineffective, with technical issues, inexperienced staff, and the complexity of programs as barriers to their use [
As with delivering PA advice [
Many participants agreed that digitization was the way forward, providing an efficient, simple, and easy-to-use solution. However, interviews were conducted during the COVID-19 pandemic, when face-to-face consultations were canceled. Before the COVID-19 pandemic, the use of digital tools instead of face-to-face PA advice was previously identified as a barrier in terms of interpersonal communication, with HCPs preferring face-to-face communication [
Previous studies have shown that knowledge, training, or access to educational resources are common barriers and facilitators to delivering PA advice [
Previous studies have identified patient-related factors as an important theme affecting the motivation of HCPs to give PA advice, with patient abilities to use digital tools, preferences, and readiness to change as barriers and facilitators [
In this study, computer-based interventions were previously proposed to facilitate the delivery of advice by acting as a prompt [
In this study, the ability to track and share patient data was considered to be a facilitator to using digital tools. Indeed, the inability to monitor follow-up is a barrier to delivering brief PA advice [
One theme in this study, largely unmentioned previously, was that digital tools may prevent mistakes and ensure patient safety by addressing the information gaps in HCPs. In addition, the participants highlighted that the time efficiency of a digital tool may depend on the extent of the safety measures used to ensure patient confidentiality, which may differ across health care systems in different countries.
The results of this study provide several recommendations for the design of a digital tool to support the delivery of PA advice by addressing barriers and leveraging facilitators. First, there appears to be a lack of digital tools that facilitate the delivery of PA advice. We argue that there is an opportunity to develop a digital tool to prompt and guide HCPs to discuss PA with patients. Second, the digital tool should be integrated into the existing workflow of primary care HCPs to reduce any friction and, most importantly, not to produce additional workload for HCPs. Therefore, we recommend developing a relevant contextual prompt at critical points within the consultation to discuss PA. Third, digital tools should facilitate conversations between HCPs and patients. It should be universally applicable to different patients, yet it should give HCPs the freedom to tailor the conversation to the patient. Fourth, the ease, simplicity, and efficiency of digital tools can address some barriers to the delivery of PA advice. However, this requires barriers to using the digital tool itself to also be addressed, such as sufficient education and training in digital tools, confidence in using digital tools, or access to in-house support for using the digital tool. For example, digital tools can be used to generate personalized, printable guides from computer-based assessments of readiness to change and PA levels, as has been recently implemented in the Portuguese National Health Service [
A strength of this study is the use of a behavioral framework for interviewing and analysis to systematically identify the barriers to and facilitators of using digital tools to deliver brief PA advice. The study also asked participants to consider any digital tool where many previous studies have focused on certain aspects of digital tools, such as eHealth or mHealth interventions.
The limitations include the range of HCP specialisms in this study, which included GPs, nurses, and HCAs and therefore did not consider the views of other HCPs within primary care. Furthermore, this study was conducted during the initial months of the COVID-19 pandemic, which may have influenced perceptions of using digital tools. Finally, barriers and facilitators to using digital tools to support the delivery of PA advice in primary care may differ across health care systems in different countries. Hence, the results from this UK study might not be applicable to other national health care systems. However, digital health care tools are becoming increasingly common worldwide, and similar issues have been identified across health care systems.
Using a behavioral framework and qualitative approach, this study systematically identified important barriers and facilitators to using digital tools to support the delivery of PA advice in primary care. Important themes were found within 8 theoretical domains, most often within physical opportunity. These barriers can be addressed by designing efficient and flexible digital support tools to facilitate HCPs in delivering PA advice in primary care. To do so, future work should combine designers, service users, and behavioral scientists to design and develop testable prototypes.
Summary of the barriers and facilitators on the use of digital systems to deliver physical activity advice in primary care.
capability, opportunity, and motivation—behavior
cardiovascular disease
general practitioner
health care assistant
health care professional
mobile health
physical activity
Theoretical Domains Framework
This is part of a wider program of work (Moving Healthcare Professionals Programme) funded by Sport England.
PB contributed to coding of the data; data analysis; and writing, reviewing, and editing the manuscript. SJD wrote, reviewed, and edited the paper and contributed to visualization. SSJ contributed to data extraction, coding, data analysis, writing the manuscript, and reviewing draft manuscript. VM contributed to study design, data collection, data extraction, coding, and reviewing draft manuscript. CS contributed to technical oversight, study design, and review draft manuscript. All authors have reviewed and contributed to the final manuscript.
None declared.