General practitioners’ educational and training needs and requirements for advising patients with coronary heart disease on physical activity: Findings from a qualitative study in Germany

General practitioners’ educational and training needs and requirements for advising patients with coronary heart disease on physical activity: Findings from a qualitative study in Germany | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article General practitioners’ educational and training needs and requirements for advising patients with coronary heart disease on physical activity: Findings from a qualitative study in Germany Alicia Prinz, Sabrina Hoppe, Rik Crutzen, Stefan Wilm, Sabrina Kastaun This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6678811/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: The World Health Organization and German treatment guidelines emphasise integrating physical activity (PA) advice into primary care of patients with coronary heart disease (CHD). However, in general practice in Germany, this is often inadequately implemented. A key barrier may be healthcare professionals’ limited knowledge and skills in providing effective and efficient PA guidance. To address this, international guidelines recommend targeted training for general practitioners (GPs). Understanding GPs' specific educational and training needs is crucial to developing tailored training programmes for improving implementation of advising CHD patients on PA. Methods: Between March and June 2023, 12 problem-centred one-on-one interviews and six moderated focus group discussions (n=37 participants) with GPs were conducted (total n=49 GPs). Interview and discussion guides were developed and pilot-tested by the multi-professional study team. Audio-recorded data were transcribed verbatim and analysed using a content structuring procedure (deductive and inductive approaches) within a multi-professional team, with active involvement of GPs. Results: In general, GPs recognise the benefits of PA for CHD patients. Their conceptualisations of PA (e.g., definitions of sport and PA, general statements on PA, on types of PA) vary and the incorporation of PA in everyday activities (e.g., using stairs) to encourage behaviour change is sometimes recommended. GPs identify the following key training needs for providing PA advice to CHD patients: peer exchange and self-reflection, evidence-based knowledge on PA and CHD, practical tools and support materials to facilitate the integration of PA advice into routine practice. These include low-barrier, time-efficient communication techniques, and role–play simulations. Conclusion: Building on own previous findings about GPs' experiences, attitudes, and beliefs regarding PA advice, the now identified educational and training needs form a foundation for developing a tailored GP training on supporting CHD patients with regard to PA. This will be implemented and evaluated in a follow-up study. General Practice Chronic ischemic heart disease coronary heart disease physical activity general practice primary care qualitative research brief intervention brief counselling education training Background In managing chronic coronary heart disease (CHD), regular physical activity (PA) is an effective measure to reduce the risk of myocardial infarction, lower cardiovascular mortality rates and all-cause hospitalisations, and to improve health-related quality in affected individuals.( 1 , 2 ) PA advice by general practitioners (GPs) can increase the chance for PA behaviour change in those receiving advice and support.( 3 – 6 ) A systematic review specifically focusing on brief interventions ( 7 ) revealed that brief advice by GPs can improve patients' self-reported and measured PA levels, at least in the medium term (up to six months). Consequently, the World Health Organization (WHO) ( 8 ), international treatment guidelines ( 9 ) and the German treatment clinical guideline on chronic coronary heart disease (CHD) ( 10 ) all recommend that HPs, including GPs, should offer advice on PA to individuals with CHD. However, PA advice from GPs appears to be inadequately integrated into German primary care.( 11 , 12 ) International qualitative studies on GPs’ experiences with lifestyle counselling in routine care ( 13 – 18 ), particularly focussing on PA ( 19 – 23 ), and those addressing other conditions than cardiovascular diseases – primarily diabetes ( 21 ) or obesity ( 24 ) –, have identified several key barriers to the routine delivery of PA advice to patients. These barriers include competing demands in daily practice, challenges in providing individualised PA advice, difficulties in assessing the PA status of patients or providing concrete information on PA opportunities. Almost all studies highlight the need of (further) education and training for HPs in how to effectively and efficiently advise patients on PA behaviour, and emphasise the importance of customised training approaches. Such training can be even more important for supporting patients living with chronic illness like CHD and addressing their specific needs.( 15 , 23 , 25 – 28 ) Appropriate training for HPs, including GPs, is also recommended by international guidelines.( 3 , 29 ) However, educational approaches on advising and supporting patients to improve their health behaviour are neither part of the medical curricula nor of vocational or continuing medical education in Germany. In order to support GPs in providing their patients with low-threshold, brief and effective advice on PA, and thus to improve preventive patient care, such training should be tailored to GPs’ specific needs and preferences for education and training. Definitely, to develop tailored training programmes for GPs in advising CHD patients on PA, in-depth information is needed on GPs’ experiences, perceptions, and attitudes regarding PA advice in everyday care.( 13 – 18 ) It is also essential to understand GPs’ specific requirements and needs for appropriate education and training. In a recent study, using data of the same study, we explored GPs’ experiences, perceptions and attitudes regarding PA advice for patients with CHD, using qualitative interviews and focus group discussions.( 30 ) Comparable to international studies, highlighting the importance of training HPs in delivering PA advice ( 15 , 25 , 26 , 31 ), our participating GPs emphasised the need for practical skills and knowledge about PA in CHD and PA advice.( 30 ) This study is part of the overarching OptiCor project (“Optimising the treatment of chronic ischemic heart disease by training general practitioners to deliver very brief advice on physical activity”).( 32 ) With OptiCor, we aim to systematically develop and evaluate a customised training for GPs in the routine delivery of efficient and effective PA advice and support to patients with CHD. In this study, we also explored GPs' experiences, perceptions, and attitudes towards PA advice for patients with CHD based on qualitative interviews and focus group discussions. To our knowledge, there are no German studies that have so far explored either whether GPs are interested in training on PA advice, or their requirements in terms of content, teaching methods, and organisation, as well as their perceived needs for delivering PA advice. We have therefore asked German GPs to envision a training on advising patients with CHD about PA. We encouraged them to reflect on their specific needs in terms of content, didactics and organisation, as well as their personal requirements for improving their PA counselling skills. In addition, we aimed to assess GPs’ existing knowledge about PA, its role in CHD, and GPs’ conceptual understanding of PA. These insights can be addressed in a training for GPs by providing clear, practical knowledge and skills to enhance PA advice to their patients. Such training might have the potential to effectively influence GPs’ practices in advising CHD patients on PA. Methods This study is reported in accordance with the consolidated criteria for reporting qualitative research (COREQ).( 33 ) The literature search for this manuscript was not conducted as a systematic review, but rather followed a structured approach, including the use of search strings (e.g., in PubMed) and a review of relevant guidelines and projects. Study Design We conducted a qualitative study using problem-centred one-on-one interviews ( 34 ) and moderated focus group discussions ( 35 , 36 ) with GPs, and analysed them using a content structuring procedure (deductive-inductive approach).( 37 ) In order to gain the deepest and broadest perspective as possible we decided to combine these two methods. While sensitive and personal revelations often occur in individual interviews without the influence of group dynamics, group dynamics in focus group discussions can help to reveal and reconstruct collective orientations, and often provide a deeper insight into collective attitudes, prejudices and problem-solving strategies.( 36 ) Recruitment and Sampling Using a purposive sampling ( 38 ), we invited 80 GPs in the German federal state of North-Rhine-Westphalia (NRW) through email or by personal invitation to participate in individual interviews. For focus group discussions, 62 regional GP networks were invited to participate. In total, 20 GPs were interested in participating in interviews and seven regional GP networks were interested in participating in focus groups. Inclusion criteria were as follows: currently practicing in general practice, general internal ambulatory medicine, or specialising in one of these fields. Participants also needed sufficient German language skills and had to sign an informed consent form before study inclusion. To ensure a broad sample of GPs, a brief questionnaire was used as part of the sampling process and the selection of GPs, conducted via telephone before each GPs’ inclusion in the study. This questionnaire is available at Open Science Framework (OSF, https://osf.io/yj9dr , in German). Because entire already existing GP networks were targeted for recruitment, it was not possible to apply specific sampling strategies at the individual GP level for participants of the group discussions. Characteristics of the resulting 49 GPs who participated in either an interview or a focus group discussion (12 interviews, six focus groups with a total of 37 GPs) are presented in Table 1 . Characteristics of the study sample have already been published in the first part of the qualitative study, and are therefore presented in the method section of this manuscript instead of the result section.( 30 ) Table 1 Characteristics of interviewed general practitioners who participated in either an interview or a focus group discussion Interviews (n = 12) Focus groups (n = 37) Total (N = 49) Sex Male 7 24 31 Female 5 13 18 Age, mean (min.-max. years) 55.4 (35–73) 56.3 (36–70) 56.1 (35–73) Migration background Yes 1 10 11 No 10 27 37 Main medical speciality General practice/family medicine 7 22 29 General internal ambulatory medicine 4 12 16 Doctor in further specialty training 1 0 1 Other 0 3 3 Years actively working as a GP, mean (min.-max. years) 17.0 ( 1 – 38 ) 19.4 ( 1 – 36 ) 18.8 ( 1 – 38 ) Type of practice Single handed practice without physician employees 3 15 18 Individual practice with physician employees 5 5 10 Joint/group practice 4 17 21 Focus on sports medicine Yes 1 6 7 No 11 31 42 Academic teaching practice Yes 11 14 25 No 1 23 24 Patients per quarter of a year 2000 5 16 21 Location of the practice Rather rural area 3 19 22 Small/medium-sized town 6 11 17 Urban area 3 7 10 Missing data per variable (age: n = 1, migration background: n = 1) Data collection The interview and focus group discussion guides aimed to address our research aims and were developed and pilot tested by the multi-professional study team comprising GPs and researchers with different backgrounds in psychology, sociology, and public health. The guides are available in German at OSF: https://osf.io/yj9dr . Between March and May 2023 the main author (female, research associate and sociologist with qualitative research and interview experience) conducted all twelve interviews in person, primarily at the GPs' practices. Interview lengths ranged from 34 to 71 minutes, with an average duration of 54 minutes. Six focus group discussions, each involving five to ten participants (n = 37 GPs in total), were conducted in person between April and June 2023 by three experienced group moderators from the study institute (all female, including a GP, the main author and a psychotherapist with longstanding research experience in general practice). An accompanying study team member (all female, research associates) took notes to assist speakers’ identification for transcription. With one exception, all focus group discussions were held in the usual locations of the GPs network meetings. Focus group discussions lasted between 72 and 92 minutes, with an average duration of 84 minutes. No interviews or focus group discussions were repeated. Field notes documented the atmosphere, conversation flow, unique aspects, and conversation disruptions. All interviews and group discussions were audio-recorded and transcribed verbatim. No professional or personal relationships existed between researchers and participants, no incentives were offered. Data analysis We analysed the data using a content structuring approach, which is a category based, language related and rule guided scientific method designed to systematically reduce complexity.( 37 ) Using both deductive and inductive techniques, we developed a coding guide and defined all categories in a category manual within the multi-professional study team (see above). All interviews and focus group discussions were coded concurrently by two researchers from a team of six coders over a period of six months. To incorporate a broad range of perspectives, feedback loops were conducted within the study team, e.g., to discuss adjustments to the coding guide. To ensure the quality of the process, we conducted two multi-professional analysis groups (6–7 participants each, including e.g., GPs and researchers with backgrounds in psychology, sociology, public health, and sport and exercise gerontology). GPs were continuously involved throughout the research process, e.g., in the creation of guides for interviews and focus group discussions, in the coding of data material and in analysis groups. Findings were revalidated in a separate workshop with GPs. All data were managed using the software MAXQDA.( 39 ) The analysis was conducted using the original German transcripts. Quotations cited in the manuscript were later translated into English and reviewed by two additional researchers. As with any translation, it is important to note that cultural and regional language nuances may influence interpretation. Results Using deductive and inductive categorisation techniques, we developed 13 main thematic categories, which were further differentiated into 28 subcategories. The complete coding tree has been published at OSF ( https://osf.io/yj9dr , translated into English). Our aim was to identify GPs specific needs and requirements regarding content, didactics, and organisation with regard to a training on PA advice and to assess their knowledge about and conceptualisation of PA in the context of CHD. Aligned with these aims we present the main findings within two thematic categories ‘knowledge about and conceptualisation of PA’ and ‘needs and requirements for a training concept’. Typical original quotations from GP interviews and group discussions translated into English are presented in Tables 2 and 3 to support the summarised results. Knowledge about and conceptualisation of PA Knowledge about PA and about PA in CHD In this category, we describe implicit knowledge and assumptions derived from statements made by the participating GPs, which reflect their knowledge about PA in in the context of patient care and specifically in the context of CHD. This includes recollections of knowledge, statements regarding the evidence of PA and PA in CHD, as well as references to gaps in knowledge and misconceptions. Most participating GPs had a general understanding of the benefits of PA, including its beneficial role in reducing cancer risk, stress and pain and enhancing the quality of life and cognitive health (quote 1a, Table 2 ). A few GPs identified physical inactivity as a risk factor for the development of non-communicable diseases (quote 1b, Table 2 ). While the majority of GPs was aware of the benefits of PA, insights into the specific evidence supporting PA in the management of CHD varied, with some GPs questioning its effectiveness in this regard. Gaps in knowledge included uncertainties about the specific effects of PA on the progression of CHD, recommended frequency and intensity of PA to balance avoiding overexertion in patients while achieving benefits for their heart disease, and specific PA recommendations, e.g., sports types (quote 1c, Table 2 ). Conceptualisation of PA The results of this category cover PA conceptualisations of the participating GPs in general patient care and in the context of CHD, e.g., definitions of sport and PA, general statements on PA, on types of PA, or statements on persons and groups that indicate GPs’ understanding of PA. GPs had varying conceptualisations of PA in the context of preventive medicine. Some GPs associated PA with different intensities or certain activities as some of their recommendations given to patients focus on performance-oriented or institutionalised approaches to PA, e.g., cardiac sports groups (quote 2a and c, Table 2 ). For some GPs, the primary goal was to encourage patients to become more active than before or at least active at all, whereas others focused on the importance of endurance training to achieve certain health effects (quote 2b and c, Table 2 ). The majority of participating GPs seemed to believe that PA is suitable for everyone, regardless of factors like age. However, some of the GPs struggled to imagine individuals with limited mobility being physically active. In this context, PA is rather recommended to younger patients without physical restrictions (quote 2d, Table 2 ). Across the different PA conceptualisations, incorporating everyday activity (e.g., taking the stairs instead of the lift) and activities that bring joy to improve PA behaviour was sometimes mentioned. In this regard, GPs discussed the advantages of everyday activities, such as their low-threshold accessibility (e.g., when going for a walk or walking the dog) and the potential for these PA activities of becoming a habit. This low-threshold approach is also used to recommend PA to patients facing barriers – such as financial limitations – which makes it difficult to access external PA offers. In this context, many of the GPs were aware of and sensitive to diverse life situations of their patients. Table 2 Quotations of the main category ‘Knowledge about and conceptualisation of PA’ organised by subcategories (translated from German into English*) Subcategory Quote No. Quotation Knowledge about PA and about PA in CHD 1a ‘You not only get a benefit in terms of your coronary heart disease, but you also lose weight, your metabolism improves, your blood pressure regulates itself, your risk of cancer minimises, you enhance your performance and your quality of life - it's a colourful bouquet of positive things.’ (HA_FG_03, GP A) 1b ‘If we know which four risk factor constellations are the ones that influence our morbidity the most, that is nicotine, alcohol, lack of physical activity, and malnutrition.’ (HA_FG_02, GP F) 1c ‘I would also find that interesting: are there any figures on how much physical activity minimises the risk, how much physical activity do I need?’ (HA_FG_01, GP A) Conceptualisation of PA 2a ‘I mean, they don't need to become top athletes, but physical activity is important. It's really not just young people, but also older individuals who need to stay active, not just sit in front of the TV and become sedentary. The goal is to improve their quality of life.’ (HA_Int_01) 2b ‘What I emphasize here is that it's not about doing high-performance sport, but about saying that any kind of physical activity is good, e.g. walking the dog is just as effective as cycling or swimming, so we should take the focus off performance[…] and instead highlight the opportunities for everyday activity.’ (HA_Int_08) 2c ‘If you then engage in sports, you have to do endurance training, otherwise it won't be as effective.’ (HA_Int_02) 2d ‘In discussions with CHD patients, there is of course also the age limit, yes? From a certain age, sport is simply no longer plausible for them, right? It´s no longer part of it.’ (HA_FG_05, GP A) *The analysis of the study is based on the original German transcripts. Quotations were subsequently translated and reviewed by two other researchers. However, every translation is also an interpretation, due to cultural and regional specific language. Needs and requirements for a training concept on brief PA counselling Content-related needs and requirements Nearly all participating GPs emphasised the need for peer exchange on advising patients about PA. Such exchange was valued for providing mutual support on daily practice, including assistance with expressing professional concern and interest about patients’ health effectively, and enhancing skills in motivational interviewing (quote 1a, Table 3 ). Some GPs also highlighted the value of guided self-reflection, e.g., through a peer trainer. Identified areas for reflection included the role and attitudes of GPs towards providing PA advice, the importance of PA advice by GPs, the omission of PA discussions in patient consultations, target groups and individuals who receive less advice (and the reasons for this), and GPs own PA behaviour (quote 1b and c, Table 3 ). The majority of participating GPs mentioned a strong need for information on evidence-based knowledge on health-beneficial effects of PA in general, in patients with CHD (e.g., compared to drug therapy), on specific PA recommendations for CHD (e.g., frequency, intensity), and on the effectiveness of GP advice on PA (quote 1d and e, Table 3 ). Few GPs asked for instructions on how to assess a patient's PA history and current PA behaviour (quote 1f, Table 3 ). Low-threshold and timesaving communication techniques for PA advice were also required from some of the participating GPs as a central aspect of a training on PA advice (e.g., conversation guides, motivational interviewing, brief advice approaches) (quote 1g, Table 3 ). In this regard participating GPs also noted specific concerns, such as overly structured discussions that may not align with empathetic and patient-centred conversations between GPs and patients, particularly in the context of long-standing patient-physician relationships. In contrast, few of the participating GPs did not express a need for further knowledge on beneficial effects of PA in CHD or on advising patients on PA. In these cases, sufficient knowledge or a higher priority on peer exchange were given as reasons (quote 1h, Table 3 ). Some participating GPs expressed the need for support materials which could be used during conversations with their patients on PA or to be passed on to patients, including visualisations of evidence-based knowledge on the effectiveness of PA in CHD, PA recommendations on frequency and intensity, patient-friendly information material on specific and low-threshold (digital) PA recommendations, a compilation of regional PA programmes for individuals with CHD, and information on reimbursement options or financial subsidies for PA programmes (e.g., from health insurance companies) (quote 1e and j, Table 3 ). Didactic-related needs and requirements The participating GPs agreed that all training content should be low-threshold, practical, directly implementable, and tailored to their specific needs (quote 2a, Table 3 ). Interactive training formats were seen as particularly beneficial, with elements that support these formats – such as small group sizes and a trusting atmosphere – being highly valued. Role plays with simulation patients (brought in by the participating GPs) were seen as effective by few participating GPs when teaching communication techniques, but were largely rejected by most of the participating GPs. A main reason seems to be that acting in front of peers is perceived as intimidating and unpleasant (quote 1i, Table 3 ). Notably, GPs expressed interest in incorporating PA into the training itself, such as through PA breaks. They suggested that experiencing the immediate effects of PA could enhance their self-awareness and motivation to provide PA advice. Additionally, some GPs proposed exercises from rehabilitation or cardiac sports programmes that could be directly recommended to patients (quote 2b and c, Table 3 ). Very few GPs expressed a need for an interdisciplinary or interprofessional training approach. Their suggestions ranged from including sports science or physical therapy expertise to designing a multiprofessional training programme involving other HPs, such as medical assistants or physiotherapists (quote 2d, Table 3 ). Organisation-related needs and requirements The preferred training format for GPs varied including online, blended learning, or face-to-face formats, and seemed to be strongly influenced by their experiences with previous training and personal factors, such as commitments to their practice or family, or long travel distances to the training location from more rural areas. However, for the majority of GPs, the format of the training did not seem to be a determining factor for their final participation (quote 3a, Table 3 ). Most GPs welcomed the integration of a training on advising CHD patients on PA into existing formats, such as mandatory vocational or continuing medical education in disease management programmes or group discussion meetings within GP networks (quote 3b, Table 3 ). Table 3 Quotations of the main category ‘Requirements and needs for training concept’ organised by subcategories (translated from German into English*) Subcategory Quote No. Quotation Content-related 1a ‘That you simply enter into a discussion with colleagues based on a specific topic or a keynote speech and then openly exchange experiences: Does it help? What experiences have you had with it? These are actually the events where you're most likely to take something away afterwards or feel validated in the way you do things.’ (HA_Int_09) 1b ‘How do we actually manage to talk about the potential for change? This involves self-motivation, external motivation, and incentives. And for me, this is closely linked to the topic of physical activity. And if you ask me, that´s actually part of it. What actually prevents us, what makes us resign ourselves in advising or with patients?’ (HA_FG_05, GP C) 1c ‘What does physical activity mean to me? Why do I think my patients don't exercise? Why don't I address this?’ (HA_Int_08) 1d ‘What impact does physical activity have compared to, for example, statin therapy in patients who already have CHD? Having a good data basis for this.’ (HA_Int_08) 1e ‘What I would find helpful is clear information on the topic: What is evidence-based with regard to CHD and physical activity? What is supported by reliable data that you can give people in a reproducible and reliable way?’ (HA_Int_12) 1f ‘How can I find out from the patient what they do and what they don't do? [...] How can I find out where they actually stand through dialogue or a brief intervention?’ (HA_FG_05, GP A) 1g ‘It's communication training. It´s about improving communication so that I can motivate the patient and this may also involve experiencing positive examples of inner attitudes towards the patient so that the conversation is successful and the patient is then able to implement physical activity.’ (HA_Int_07) 1h ‘It's about talking about, seeing, and hearing what colleagues say or advise in certain situations. It's not about acquiring new cognitive knowledge. I think that's obvious, everyone knows it, everyone has it at hand.’ (HA_Int_10) 1i ‘So, the training sessions that I benefited from also involved roleplays [...] of course that's a super uncomfortable situation, you don't really want to be in it, but it's incredibly useful [...] when you're sitting there uninvolved and then: Hmm, why isn't the colleague engaging with this? But I also found it very helpful to see how certain things caused a reaction and to really experience that. I was able to take a lot with me back then, I don´t want to say that I always manage it, but I really took a few key things with me and found it extremely helpful.’ (HA_FG_04, GP B) 1j What would appeal to me would be exercise programmes that are easy to implement, simple tips on that. There are also sports programmes that are not very well-known, but which would be good to find out more about what options are available.’ (HA_Int_06) Didactic-related 2a ‘It's great to be at a new level here. Especially, as I said, whenever it´s suitable for everyday use, when I think: I can put it into practice like this.’ (HA_Int_04) 2b ‘An exercise program, a kind of take-away effect, something that is exciting for you, so that you don´t just learn: What can I do for other people? But also gaining something good for yourself. For me personally, for example, it would be great to have something like yoga in the evening, I think that would be nice. If you could combine that with a practical part and do something like that.’ (HA_Int_08) 2c ‘What I would really be interested in is: What do they do in the cardiac exercise groups, and what does it look like? What do they do right, and what might they be doing wrong? It would be helpful to actually experience it, maybe even taking part in a session yourself. Then you realise what you can recommend to patients and what not.’ (HA_Int_12) 2d ´Also, to talk to sports scientists or something, so it's not just one-sided from the medical perspective, but also includes input from other areas, from physiotherapy, for example.’ (HA_Int_01) Organisation-related 3a ‘But apart from that, I very rarely go to training courses. So I do it in writing at home. I: What exactly stops you from doing that? P: [exhales] Very practically: I have a wife who works full time three children at home.’ (HA_Int_11) 3b ‘So not an additional event on top of the existing DMP obligations, because that often requires a lot of time and effort anyway. But within the framework of these training course, it would be good to say: Okay, this is a simple tool for the care of CHD patients, because it is inexpensive, low-effort and can be customised. "’ (HA_Int_08) *The analysis of the study is based on the original German transcripts. Quotations were subsequently translated and reviewed by two other researchers. However, every translation is also an interpretation, due to cultural and regional specific language. Discussion Principal findings The present study focusses on German GPs’ target-group specific needs and requirements regarding content, organisation and didactics towards a training on PA advice to their patients as well as on their knowledge about and conceptualisations of PA and of PA in CHD patient care. Together with results from our earlier work,( 30 ) we aim to inform the design of a target-group oriented GP training in the effective and efficient provision of advice on PA during routine consultations with CHD patients. Our findings show that most participating GPs have general knowledge of the health beneficial effects of PA (e.g., minimising the risk of cancer, impact on quality of life). However, with regard to knowledge on specific PA recommendations for patients with CHD in terms of type, intensity, concrete PA recommendations, or proven effects on CHD management, GPs express the need for more evidence-based information. We do not find a consistent conceptualisation of PA in the context of preventive medicine. While some GPs incorporate the idea of everyday exercise – an approach proven to be beneficial and adaptable for diverse patients – this does not seem to be widely applied. In contrast, a few recommendations focus on performance-oriented or institutionalised approaches to PA, such as the recommendation of cardiac sports groups. This highlights an opportunity to emphasise and train GPs on the importance of everyday activity, underscoring the concept that ´every step or every minute counts´.( 40 , 41 ) Our findings show a clear need for peer exchange and reflection on PA in the care of patients with CHD and in advising patients on PA. Some GPs lack a clear understanding of how to provide effective and efficient PA advice or counselling. The need for peer exchange could be driven by factors such as the desire for feedback and validation of their approach to discussing PA with patients, as well as fostering a positive attitude and role in promoting PA and related advice. Allocating some time for a structured dialogue – facilitated by a peer trainer who poses reflective questions and introduces accessible methods for advising on PA – could address these needs effectively. When it comes to specific didactics and organisational aspects of training in the provision of PA advice, GPs outline relatively detailed, practical, and realistic requirements. These include low-threshold, practically relevant, and directly implementable training content that address their specific needs. They also emphasised the importance of support materials on PA, both for their own use and to share with patients. Considering the unique context of GP care – such as the longstanding patient-physician relationship – and ensuring the practical relevance of training content seem to be crucial to its acceptance. Comparison with existing literature GPs’ lack of education and training may contribute to gaps in knowledge and skills, as well as to unsatisfactory experiences in providing PA advice to patients.( 30 , 42 , 43 ) However, to the best of our knowledge, there are no qualitative studies in Germany that have investigated in depth the knowledge and conceptual understanding of PA in the context of CHD patient care among GPs, as well as the content, organisational, and didactic requirements for a GP training on PA advice. Some quantitative studies have examined GPs’ knowledge and competence regarding various health aspects, including the frequency of PA advice.( 43 , 44 ) For example, a German study that about the promotion of PA among older adults found that physicians (n = 60, including 48 GPs) rated their knowledge about PA and their skills in initiating and advising on PA at an intermediate level.( 44 ) A study from the United Kingdom concluded that 80% of GPs were unfamiliar with the national PA guidelines.( 43 ) Our findings on knowledge partially align with those of a qualitative study conducted in Ireland, which used semi-structured online interviews with HPs.( 45 ) Although the majority of the 63 participants were not GPs (only 16%) the participants recognised the general benefit of PA and demonstrated knowledge of specific areas, such as fall prevention.( 45 ) Despite methodological differences to our study, the Irish study’s insights into the support HPs need to deliver effective and efficient PA advice are consistent with our results. The HPs interviewed expressed the need for tailored educational opportunities, emphasising brief, practical training sessions grounded on real-life scenarios and simulated GP consultations.( 45 ) Parallels can also be drawn with the above mentioned German questionnaire survey in physicians, where they were asked about preferred types of information and training formats.( 44 ) The majority of participants (n = 38/60) favoured a short seminar, while 27 participants expressed interest in a brief self-administered intervention, and 37 participants were interested in patient materials.( 44 ) Participants in another German qualitative study about health promotion in primary care highlighted the preference for digitally accessible, innovatively designed informational materials, along with an overview of where to find information on specific topics.( 46 ) Other studies from the UK, Canada and Finland have proposed training concepts for advising patients on PA.( 43 , 47 , 48 ) In most cases, the training components – such as assessing patients’ PA level, using motivational interviewing techniques to promote PA, and providing written PA instructions – are derived from quantitative studies.( 47 ) These studies underscore a lack of training, knowledge, or tools for prescribing PA ( 43 ). However, it remains unclear to what extent the developed training programmes are grounded in the findings of these studies.( 49 ) Notably, some components of these developed trainings overlap with those mentioned by the GPs we interviewed, such as the peer-to-peer approach.( 50 ) This highlights the importance of integrating evidence-based strategies with practical, context-specific elements when designing training programmes for PA advice. Strengths and weaknesses of the study The continuous involvement of the target group in the development of interview guides, analysis and interpretation of the data is the main strength of this qualitative study. Results were thus consistently reviewed and validated from individuals with different perspectives. In addition, all data were double-coded (primary and control), which contributes to the quality of the coding process and findings following from those. The study also has limitations. GPs who agreed to participate might more likely have an interest in providing lifestyle and PA advice, which may have motivated them to share their experiences. Furthermore, their personal interests could have also influenced their shared experiences. In order to still capture a diverse range of GPs and their perspectives (e.g., in terms of professional experience, practice location, and interest in PA), and to minimise the potential selection bias, we used multiple sampling strategies: For focus group discussions, we aimed to include all GPs of a GPs network, which may have increased the chance to include also GPs less interested in lifestyle counselling. However, GPs networks also attract specific characters, such as individuals particularly interested in sharing and learning from colleagues. Conclusion This qualitative study provides detailed insights into German GPs knowledge of PA and conceptualisations of PA in the context of caring for patients with CHD, as well as their content, didactic, and organisational needs for a training on the routine delivery of PA advice to these patients. Combined with our earlier analysis of their experiences, perceptions, and attitudes towards PA and towards advising on PA ( 30 ), these findings are essential for systematically developing a tailored training designed to positively influencing GPs’ practices in advising CHD patients on PA. Abbreviations COREQ Consolidated Criteria for Reporting Qualitative Research DMP Disease Management Programme GP General practitioner HP Health professional CHD Coronary heart disease NCDs Non-communicable diseases NRW North-Rhine-Westphalia OSF Open Science Framework PA Physical Activity WHO World Health Organization Declarations Ethics approval and consent to participate This study was approved by the ethics committee of Heinrich-Heine-University Düsseldorf, Germany (2022-2237, 06.03.2023). Consent for publication Not applicable. Availability of data and materials All data relevant to the study are included in the article or uploaded as online supplemental information. Competing interests AP, SH, RC and SW have no competing interests to declare. SK has received public funding from the German Ministry of Education and Research (BMBF) to conduct the study, although the funder is not involved in the design, analyses, or reporting of the study. Funding The OptiCor project has been funded as a junior research group in health services research by the German Ministry of Education and Research (BMBF) (funding period: 05/2022-04/2027, grant number: 01GY2103). Authors´ contributions AP drafted the manuscript and conducted all preparatory work for the study. SK conceived of the study, acquired funding for the study, co-wrote this paper, and supervised all preparatory work. RC and SW participated in the design of the study. AP, SH and SK interpreted the data. All named authors contributed substantially to the manuscript and agreed on its final version. All authors read an approved the final manuscript. Acknowledgements The authors gratefully acknowledge the time given by the GPs who participated in this study. We would like to thank Angela Fuchs (psychologist) and Lisa Gummersbach (GP) for the conduction of some of the focus group discussions, Franziska Vogl (student assistant) and Gabriele Franken (GP) for their support with the control coding, Leonie Bamberg (student assistant) for the translation of the quotations and Olaf Reddemann (GP) and Verena Leve (sociologist, researcher) for their support during the analysis. References Dibben GO, Faulkner J, Oldridge N, Rees K, Thompson DR, Zwisler AD, et al. Exercise-based cardiac rehabilitation for coronary heart disease: a meta-analysis. Eur Heart J . 2023;44(6):452-69. Vuori I, Andersen LB, Cavill N. Physical activity policies for cardiovascular health. European Heart Network.; 2019. Orrow G, Kinmonth AL, Sanderson S, Sutton S. Effectiveness of physical activity promotion based in primary care: systematic review and meta-analysis of randomised controlled trials. BMJ . 2012;344. Sanchez A, Bully P, Martinez C, Grandes G. Effectiveness of physical activity promotion interventions in primary care: A review of reviews. Prev Med . 2015;76:56-67. Sanchez A, Grandes G, Ortega Sánchez-Pinilla R, Torcal J, Montoya I. Predictors of long-term change of a physical activity promotion programme in primary care. BMC Public Health. 2014;14. Patnode CD, Evans CV, Senger CA, Redmond N, Lin JS. Behavioral Counseling to Promote a Healthful Diet and Physical Activity for Cardiovascular Disease Prevention in Adults Without Known Cardiovascular Disease Risk Factors: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. Jama . 2017;318(2):175-93. Green ET, Cox NS, Arden CM, Warren CJ, Holland AE. What is the effect of a brief intervention to promote physical activity when delivered in a health care setting? A systematic review. Health Promot J Austral . 2023;34:809–24. World Health Organization. Global action plan on physical activity 2018-2030: more active people for a healthier world. 2019. Campbell F, Blank L, Messina J, Day M, Woods HB, Payne N, et al. Physical activity: Brief advice for adults in primary care. Public Health Intervention Guidance . National Institute for Health and Clinical Excellence ; 2012. Federal Medical Association [Bundesaerztekammer], The National Association of Statutory Health Insurance Physicians [Kassenärztliche Bundesvereinigung], Working Group of Scientific Medical Societies [Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften]. National Disease Management Guidelines - Chronic Coronary Heart Disease - long version [Nationale VersorgungsLeitlinie Chronische KHK - Langfassung]. 2019. Gabrys L, Jordan S, Schlaud M. Prevalence and temporal trends of physical activity counselling in primary health care in Germany from 1997-1999 to 2008-2011. Int J Behav Nutr Phys Act . 2015;12(136):1-8. Hinrichs T, Moschny A, Klaaßen-Mielke R, Trampisch U, Thiem U, Platen P. General practitioner advice on physical activity: Analyses in a cohort of older primary health care patients (getABI). BMC Fam Pract . 2011;12(26). Lambe B, Collins C. A qualitative study of lifestyle counselling in general practice in Ireland. Fam Pract . 2010;27(2):219-23. Ampt AJ, Amoroso C, Harris MF, McKenzie SH, Rose VK, Taggart JR. Attitudes, norms and controls influencing lifestyle risk factor management in general practice. BMC Family Practice . 2009;10(1):59. Caiata-Zufferey M, De Pietro C. Motivational interviewing for prevention in Swiss family medicine: Opportunities and challenges. Prev Med Rep . 2023;35:102351. Aira M, Kauhanen J, Larivaara P, Rautio P. Differences in brief interventions on excessive drinking and smoking by primary care physicians: qualitative study. Preventive Medicine . 2004;38(4):473-8. Beich A, Gannik D, Malterud K. Screening and brief intervention for excessive alcohol use: qualitative interview study of the experiences of general practitioners. BMJ . 2002;325(7369):870. Geirsson M, Bendtsen P, Spak F. Attitudes of Swedish general practitioners and nurses to working with lifestyle change, with special reference to alcohol consumption. Alcohol Alcohol. 2005;40(5):388-93. Din NU, Moore GF, Murphy S, Wilkinson C, Williams NH. Health professionals' perspectives on exercise referral and physical activity promotion in primary care: Findings from a process evaluation of the National Exercise Referral Scheme in Wales. Health Educ J . 2015;74(6):743-57. Huijg JM, van der Zouwe N, Crone MR, Verheijden MW, Middelkoop BJC, Gebhardt WA. Factors Influencing the Introduction of Physical Activity Interventions in Primary Health Care: a Qualitative Study. International Journal of Behavioral Medicine . 2015;22(3):404-14. Kime N, Pringle A, Zwolinsky S, Vishnubala D. How prepared are healthcare professionals for delivering physical activity guidance to those with diabetes? A formative evaluation. BMC Health Services Research . 2020;20(1):8. Puig Ribera A, McKenna J, Riddoch C. Attitudes and practices of physicians and nurses regarding physical activity promotion in the Catalan primary health-care system. Eur J Public Health . 2005;15(6):569-75. Buckley BJR, Finnie SJ, Murphy RC, Watson PM. “You’ve Got to Pick Your Battles”: A Mixed-Methods Investigation of Physical Activity Counselling and Referral within General Practice. International Journal of Environmental Research and Public Health . 2020;17(20):7428. Tremblett M, Poon AYX, Aveyard P, Albury C. What advice do general practitioners give to people living with obesity to lose weight? A qualitative content analysis of recorded interactions. Family Practice . 2022;40(5-6):789-95. Calderón C, Balagué L, Cortada JM, Sánchez Á. Health promotion in primary care: How should we intervene? A qualitative study involving both physicians and patients. BMC Health Services Research . 2011;11(1):62. Albert FA, Crowe MJ, Malau-Aduli AEO, Malau-Aduli BS. Physical Activity Promotion: A Systematic Review of The Perceptions of Healthcare Professionals. Int J Environ Res Public Health . 2020;17(12):4358. Wattanapisit A, Thanamee S, Wongsiri S. Physical activity counselling among GPs: a qualitative study from Thailand. BMC Family Practice . 2019;20(1):72. Cunningham C, O'Sullivan R. Healthcare Professionals' Application and Integration of Physical Activity in Routine Practice with Older Adults: A Qualitative Study. Int J Environ Res Public Health. 2021;18(21). Physical activity: brief advice for adults in primary care. Public health guideline. National Institute for Health and Care Excellence (NICE); 2013. Prinz A, Hoppe S, Leve V, al. e. Experiences, perceptions and attitudes on providing advice on physical activity to patients with chronic ischemic heart disease – A qualitative study in general practitioners in Germany, 23 July 2024. PREPRINT (Version 1) Available at Research Square [https://doiorg/1021203/rs3rs-4777870/v1]. Williams SJ, Calnan M. Perspectives on prevention: the views of General Practitioners. Sociology of Health & Illness . 1994;16(3):372-93. Hoppe S, Prinz A, Crutzen R, Donner-Banzhoff N, Icks A, Kotz D, et al. Optimising the treatment of chronic ischemic heart disease by training general practitioners to deliver very brief advice on physical activity (OptiCor): protocol of the systematic development and evaluation of a complex intervention. BMC Primary Care. 2024;25(1):404. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. International journal for quality in health care . 2007;19(6):349-57. Witzel A. The Problem-Centered Interview [Das problemzentrierte interview]. Forum Qualitative Sozialforschung Forum: Qualitative Social Research . 2000;1(1):22. Schulz M, Mack B, Renn O. Focus groups in empitical social science: from conception to evaluation [Fokusgruppen in der empirischen Sozialwissenschaft: Von der Konzeption bis zur Auswertung]. 1 ed. Wiesbaden: VS Verlag für Sozialwissenschaften Wiesbaden; 2012. 209 p. Bohnsack R, Przyborski A, Schäffer B. The group discussion procedure in research practice [Das Gruppendiskussionsverfahren in der Forschungspraxis]. Opladen: Budrich; 2006. Kuckartz U. Qualitative content analysis. Methods, practice, computer suppport [Qualitative Inhaltsanalyse. Methoden, Praxis, Computerunterstützung]. 3 ed. Weinheim, Basel: Beltz Juventa; 2016. Patton MQ. Qualitative evaluation and research methods, 2nd ed. Thousand Oaks, CA, US: Sage Publications, Inc; 1990. 532- p. VERBI Software. MAXQDA 2022. Banach M, Lewek J, Surma S, Penson PE, Sahebkar A, Martin SS, et al. The association between daily step count and all-cause and cardiovascular mortality: a meta-analysis. Eur J Prev Cardiol. 2023;30(18):1975-85. Moving Medicine. Increase walking. 12-week PACE-UP programme to help you increase your walking. 2020. Available at https://movingmedicine.ac.uk/wp-content/uploads/sites/5/2022/04/PACE-up-MM-edit-v92.pdf. McPhail S, Schippers M. An evolving perspective on physical activity counselling by medical professionals. BMC Family Practice. 2012;13(1):31. Buckley BJR, Finnie SJ, Murphy RC, Watson PM. "You've Got to Pick Your Battles": A Mixed-Methods Investigation of Physical Activity Counselling and Referral within General Practice. Int J Environ Res Public Health. 2020;17(20). Peters S, Schwab M, Faller H, Meng K. Training for physicians for physical activity promotion in older adults [Schulung für Ärzte zur Bewegungsförderung bei Älteren]. Prävention und Gesundheitsförderung . 2017;12(3):218-26. Cunningham C, R OS. Healthcare Professionals' Application and Integration of Physical Activity in Routine Practice with Older Adults: A Qualitative Study. Int J Environ Res Public Health . 2021;18(21):11222. Engler J, Schütze D, Gerber M, Dieckelmann M, Siebenhofer-Kroitzsch A. Field of action analysis of health promotion in the GP practice (GeHa) [Handlungsfeldanalyse Gesundheitsförderung in der Hausarztpraxis (GeHa)]. Berlin: Health Knowledge Foundation [Stiftung Gesundheitswissen]; 2023. Windt J, Windt A, Davis J, Petrella R, Khan K. Can a 3-hour educational workshop and the provision of practical tools encourage family physicians to prescribe physical activity as medicine? A pre-post study. BMJ Open. 2015;5(7):e007920. Aittasalo M, Kukkonen-Harjula K, Toropainen E, Rinne M, Tokola K, Vasankari T. Developing physical activity counselling in primary care through participatory action approach. BMC Fam Pract. 2016;17(1):141. Brannan M, Bernardotto M, Clarke N, Varney J. Moving healthcare professionals - a whole system approach to embed physical activity in clinical practice. BMC Med Educ. 2019;19(1):84. Brannan M, Hughes-Short M. The Moving Healthcare Professionals Programme. British Journal of General Practice. 2020;70(suppl 1):bjgp20X711341. Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6678811","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":457503208,"identity":"8c52de9a-9a41-4740-95b5-40d4f3bf71be","order_by":0,"name":"Alicia Prinz","email":"","orcid":"https://orcid.org/0009-0008-8159-7414","institution":"Institute of General Practice (ifam), Patient-Physician-Communication Research Unit, Centre for Health and Society (chs), Medical Faculty and University Hospital of Heinrich-Heine-University, Düsseldorf, 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Germany","correspondingAuthor":true,"prefix":"","firstName":"Sabrina","middleName":"","lastName":"Kastaun","suffix":""}],"badges":[],"createdAt":"2025-05-16 08:34:48","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-6678811/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6678811/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":83026632,"identity":"4d89b74e-e891-4919-a80a-9a918d07c09f","added_by":"auto","created_at":"2025-05-19 08:32:37","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1095200,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6678811/v1/f83e170d-022c-4cbc-bb4a-d2dfbb69bb09.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eGeneral practitioners’ educational and training needs and requirements for advising patients with coronary heart disease on physical activity: Findings from a qualitative study in Germany\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eIn managing chronic coronary heart disease (CHD), regular physical activity (PA) is an effective measure to reduce the risk of myocardial infarction, lower cardiovascular mortality rates and all-cause hospitalisations, and to improve health-related quality in affected individuals.(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003cp\u003ePA advice by general practitioners (GPs) can increase the chance for PA behaviour change in those receiving advice and support.(\u003cspan additionalcitationids=\"CR4 CR5\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) A systematic review specifically focusing on brief interventions (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) revealed that brief advice by GPs can improve patients' self-reported and measured PA levels, at least in the medium term (up to six months). Consequently, the World Health Organization (WHO) (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e), international treatment guidelines (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) and the German treatment clinical guideline on chronic coronary heart disease (CHD) (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) all recommend that HPs, including GPs, should offer advice on PA to individuals with CHD.\u003c/p\u003e \u003cp\u003eHowever, PA advice from GPs appears to be inadequately integrated into German primary care.(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e) International qualitative studies on GPs\u0026rsquo; experiences with lifestyle counselling in routine care (\u003cspan additionalcitationids=\"CR14 CR15 CR16 CR17\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e), particularly focussing on PA (\u003cspan additionalcitationids=\"CR20 CR21 CR22\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e), and those addressing other conditions than cardiovascular diseases \u0026ndash; primarily diabetes (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e) or obesity (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e) \u0026ndash;, have identified several key barriers to the routine delivery of PA advice to patients. These barriers include competing demands in daily practice, challenges in providing individualised PA advice, difficulties in assessing the PA status of patients or providing concrete information on PA opportunities. Almost all studies highlight the need of (further) education and training for HPs in how to effectively and efficiently advise patients on PA behaviour, and emphasise the importance of customised training approaches. Such training can be even more important for supporting patients living with chronic illness like CHD and addressing their specific needs.(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan additionalcitationids=\"CR26 CR27\" citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e Appropriate training for HPs, including GPs, is also recommended by international guidelines.(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e) However, educational approaches on advising and supporting patients to improve their health behaviour are neither part of the medical curricula nor of vocational or continuing medical education in Germany.\u003c/p\u003e \u003cp\u003eIn order to support GPs in providing their patients with low-threshold, brief and effective advice on PA, and thus to improve preventive patient care, such training should be tailored to GPs\u0026rsquo; specific needs and preferences for education and training. Definitely, to develop tailored training programmes for GPs in advising CHD patients on PA, in-depth information is needed on GPs\u0026rsquo; experiences, perceptions, and attitudes regarding PA advice in everyday care.(\u003cspan additionalcitationids=\"CR14 CR15 CR16 CR17\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e) It is also essential to understand GPs\u0026rsquo; specific requirements and needs for appropriate education and training.\u003c/p\u003e \u003cp\u003eIn a recent study, using data of the same study, we explored GPs\u0026rsquo; experiences, perceptions and attitudes regarding PA advice for patients with CHD, using qualitative interviews and focus group discussions.(\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e) Comparable to international studies, highlighting the importance of training HPs in delivering PA advice (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e), our participating GPs emphasised the need for practical skills and knowledge about PA in CHD and PA advice.(\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eThis study is part of the overarching OptiCor project (\u0026ldquo;Optimising the treatment of chronic ischemic heart disease by training general practitioners to deliver very brief advice on physical activity\u0026rdquo;).(\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e) With OptiCor, we aim to systematically develop and evaluate a customised training for GPs in the routine delivery of efficient and effective PA advice and support to patients with CHD. In this study, we also explored GPs' experiences, perceptions, and attitudes towards PA advice for patients with CHD based on qualitative interviews and focus group discussions.\u003c/p\u003e \u003cp\u003eTo our knowledge, there are no German studies that have so far explored either whether GPs are interested in training on PA advice, or their requirements in terms of content, teaching methods, and organisation, as well as their perceived needs for delivering PA advice. We have therefore asked German GPs to envision a training on advising patients with CHD about PA. We encouraged them to reflect on their specific needs in terms of content, didactics and organisation, as well as their personal requirements for improving their PA counselling skills. In addition, we aimed to assess GPs\u0026rsquo; existing knowledge about PA, its role in CHD, and GPs\u0026rsquo; conceptual understanding of PA. These insights can be addressed in a training for GPs by providing clear, practical knowledge and skills to enhance PA advice to their patients. Such training might have the potential to effectively influence GPs\u0026rsquo; practices in advising CHD patients on PA.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis study is reported in accordance with the consolidated criteria for reporting qualitative research (COREQ).(\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e) The literature search for this manuscript was not conducted as a systematic review, but rather followed a structured approach, including the use of search strings (e.g., in PubMed) and a review of relevant guidelines and projects.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design\u003c/h2\u003e \u003cp\u003eWe conducted a qualitative study using problem-centred one-on-one interviews (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e) and moderated focus group discussions (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e) with GPs, and analysed them using a content structuring procedure (deductive-inductive approach).(\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e) In order to gain the deepest and broadest perspective as possible we decided to combine these two methods. While sensitive and personal revelations often occur in individual interviews without the influence of group dynamics, group dynamics in focus group discussions can help to reveal and reconstruct collective orientations, and often provide a deeper insight into collective attitudes, prejudices and problem-solving strategies.(\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e)\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eRecruitment and Sampling\u003c/h3\u003e\n\u003cp\u003eUsing a purposive sampling (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e), we invited 80 GPs in the German federal state of North-Rhine-Westphalia (NRW) through email or by personal invitation to participate in individual interviews. For focus group discussions, 62 regional GP networks were invited to participate.\u003c/p\u003e \u003cp\u003eIn total, 20 GPs were interested in participating in interviews and seven regional GP networks were interested in participating in focus groups. Inclusion criteria were as follows: currently practicing in general practice, general internal ambulatory medicine, or specialising in one of these fields. Participants also needed sufficient German language skills and had to sign an informed consent form before study inclusion.\u003c/p\u003e \u003cp\u003eTo ensure a broad sample of GPs, a brief questionnaire was used as part of the sampling process and the selection of GPs, conducted via telephone before each GPs\u0026rsquo; inclusion in the study. This questionnaire is available at Open Science Framework (OSF, \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://osf.io/yj9dr\u003c/span\u003e\u003cspan address=\"https://osf.io/yj9dr\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e, in German). Because entire already existing GP networks were targeted for recruitment, it was not possible to apply specific sampling strategies at the individual GP level for participants of the group discussions.\u003c/p\u003e \u003cp\u003eCharacteristics of the resulting 49 GPs who participated in either an interview or a focus group discussion (12 interviews, six focus groups with a total of 37 GPs) are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Characteristics of the study sample have already been published in the first part of the qualitative study, and are therefore presented in the method section of this manuscript instead of the result section.(\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of interviewed general practitioners who participated in either an interview or a focus group discussion\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInterviews\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;12)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFocus groups\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;37)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;49)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge, mean (min.-max. years)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55.4 (35\u0026ndash;73)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e56.3 (36\u0026ndash;70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e56.1 (35\u0026ndash;73)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMigration background\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMain medical speciality\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGeneral practice/family medicine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGeneral internal ambulatory medicine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDoctor in further specialty training\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eYears actively working as a GP, mean (min.-max. years)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17.0\u003c/p\u003e \u003cp\u003e(\u003cspan additionalcitationids=\"CR2 CR3 CR4 CR5 CR6 CR7 CR8 CR9 CR10 CR11 CR12 CR13 CR14 CR15 CR16 CR17 CR18 CR19 CR20 CR21 CR22 CR23 CR24 CR25 CR26 CR27 CR28 CR29 CR30 CR31 CR32 CR33 CR34 CR35 CR36 CR37\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19.4\u003c/p\u003e \u003cp\u003e(\u003cspan additionalcitationids=\"CR2 CR3 CR4 CR5 CR6 CR7 CR8 CR9 CR10 CR11 CR12 CR13 CR14 CR15 CR16 CR17 CR18 CR19 CR20 CR21 CR22 CR23 CR24 CR25 CR26 CR27 CR28 CR29 CR30 CR31 CR32 CR33 CR34 CR35\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18.8\u003c/p\u003e \u003cp\u003e(\u003cspan additionalcitationids=\"CR2 CR3 CR4 CR5 CR6 CR7 CR8 CR9 CR10 CR11 CR12 CR13 CR14 CR15 CR16 CR17 CR18 CR19 CR20 CR21 CR22 CR23 CR24 CR25 CR26 CR27 CR28 CR29 CR30 CR31 CR32 CR33 CR34 CR35 CR36 CR37\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eType of practice\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSingle handed practice without physician employees\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndividual practice with physician employees\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJoint/group practice\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFocus on sports medicine\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAcademic teaching practice\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePatients per quarter of a year\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;1000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1000\u0026ndash;2000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;2000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLocation of the practice\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRather rural area\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSmall/medium-sized town\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrban area\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eMissing data per variable (age: n\u0026thinsp;=\u0026thinsp;1, migration background: n\u0026thinsp;=\u0026thinsp;1)\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eThe interview and focus group discussion guides aimed to address our research aims and were developed and pilot tested by the multi-professional study team comprising GPs and researchers with different backgrounds in psychology, sociology, and public health. The guides are available in German at OSF: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://osf.io/yj9dr\u003c/span\u003e\u003cspan address=\"https://osf.io/yj9dr\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eBetween March and May 2023 the main author (female, research associate and sociologist with qualitative research and interview experience) conducted all twelve interviews in person, primarily at the GPs' practices. Interview lengths ranged from 34 to 71 minutes, with an average duration of 54 minutes.\u003c/p\u003e \u003cp\u003eSix focus group discussions, each involving five to ten participants (n\u0026thinsp;=\u0026thinsp;37 GPs in total), were conducted in person between April and June 2023 by three experienced group moderators from the study institute (all female, including a GP, the main author and a psychotherapist with longstanding research experience in general practice). An accompanying study team member (all female, research associates) took notes to assist speakers\u0026rsquo; identification for transcription. With one exception, all focus group discussions were held in the usual locations of the GPs network meetings. Focus group discussions lasted between 72 and 92 minutes, with an average duration of 84 minutes.\u003c/p\u003e \u003cp\u003eNo interviews or focus group discussions were repeated. Field notes documented the atmosphere, conversation flow, unique aspects, and conversation disruptions. All interviews and group discussions were audio-recorded and transcribed verbatim. No professional or personal relationships existed between researchers and participants, no incentives were offered.\u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eWe analysed the data using a content structuring approach, which is a category based, language related and rule guided scientific method designed to systematically reduce complexity.(\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e) Using both deductive and inductive techniques, we developed a coding guide and defined all categories in a category manual within the multi-professional study team (see above). All interviews and focus group discussions were coded concurrently by two researchers from a team of six coders over a period of six months. To incorporate a broad range of perspectives, feedback loops were conducted within the study team, e.g., to discuss adjustments to the coding guide. To ensure the quality of the process, we conducted two multi-professional analysis groups (6\u0026ndash;7 participants each, including e.g., GPs and researchers with backgrounds in psychology, sociology, public health, and sport and exercise gerontology). GPs were continuously involved throughout the research process, e.g., in the creation of guides for interviews and focus group discussions, in the coding of data material and in analysis groups. Findings were revalidated in a separate workshop with GPs. All data were managed using the software MAXQDA.(\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eThe analysis was conducted using the original German transcripts. Quotations cited in the manuscript were later translated into English and reviewed by two additional researchers. As with any translation, it is important to note that cultural and regional language nuances may influence interpretation.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eUsing deductive and inductive categorisation techniques, we developed 13 main thematic categories, which were further differentiated into 28 subcategories. The complete coding tree has been published at OSF (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://osf.io/yj9dr\u003c/span\u003e\u003cspan address=\"https://osf.io/yj9dr\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e, translated into English). Our aim was to identify GPs specific needs and requirements regarding content, didactics, and organisation with regard to a training on PA advice and to assess their knowledge about and conceptualisation of PA in the context of CHD. Aligned with these aims we present the main findings within two thematic categories \u0026lsquo;knowledge about and conceptualisation of PA\u0026rsquo; and \u0026lsquo;needs and requirements for a training concept\u0026rsquo;.\u003c/p\u003e \u003cp\u003eTypical original quotations from GP interviews and group discussions translated into English are presented in Tables\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e to support the summarised results.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eKnowledge about and conceptualisation of PA\u003c/h2\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003eKnowledge about PA and about PA in CHD\u003c/h2\u003e \u003cp\u003eIn this category, we describe implicit knowledge and assumptions derived from statements made by the participating GPs, which reflect their knowledge about PA in in the context of patient care and specifically in the context of CHD. This includes recollections of knowledge, statements regarding the evidence of PA and PA in CHD, as well as references to gaps in knowledge and misconceptions.\u003c/p\u003e \u003cp\u003eMost participating GPs had a general understanding of the benefits of PA, including its beneficial role in reducing cancer risk, stress and pain and enhancing the quality of life and cognitive health (quote 1a, Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). A few GPs identified physical inactivity as a risk factor for the development of non-communicable diseases (quote 1b, Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWhile the majority of GPs was aware of the benefits of PA, insights into the specific evidence supporting PA in the management of CHD varied, with some GPs questioning its effectiveness in this regard. Gaps in knowledge included uncertainties about the specific effects of PA on the progression of CHD, recommended frequency and intensity of PA to balance avoiding overexertion in patients while achieving benefits for their heart disease, and specific PA recommendations, e.g., sports types (quote 1c, Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e\n\u003ch3\u003eConceptualisation of PA\u003c/h3\u003e\n\u003cp\u003eThe results of this category cover PA conceptualisations of the participating GPs in general patient care and in the context of CHD, e.g., definitions of sport and PA, general statements on PA, on types of PA, or statements on persons and groups that indicate GPs\u0026rsquo; understanding of PA.\u003c/p\u003e \u003cp\u003eGPs had varying conceptualisations of PA in the context of preventive medicine. Some GPs associated PA with different intensities or certain activities as some of their recommendations given to patients focus on performance-oriented or institutionalised approaches to PA, e.g., cardiac sports groups (quote 2a and c, Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). For some GPs, the primary goal was to encourage patients to become more active than before or at least active at all, whereas others focused on the importance of endurance training to achieve certain health effects (quote 2b and c, Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe majority of participating GPs seemed to believe that PA is suitable for everyone, regardless of factors like age. However, some of the GPs struggled to imagine individuals with limited mobility being physically active. In this context, PA is rather recommended to younger patients without physical restrictions (quote 2d, Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAcross the different PA conceptualisations, incorporating everyday activity (e.g., taking the stairs instead of the lift) and activities that bring joy to improve PA behaviour was sometimes mentioned. In this regard, GPs discussed the advantages of everyday activities, such as their low-threshold accessibility (e.g., when going for a walk or walking the dog) and the potential for these PA activities of becoming a habit. This low-threshold approach is also used to recommend PA to patients facing barriers \u0026ndash; such as financial limitations \u0026ndash; which makes it difficult to access external PA offers. In this context, many of the GPs were aware of and sensitive to diverse life situations of their patients.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eQuotations of the main category \u0026lsquo;Knowledge about and conceptualisation of PA\u0026rsquo; organised by subcategories (translated from German into English*)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSubcategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eQuote No.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eQuotation\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eKnowledge about PA and about PA in CHD\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lsquo;You not only get a benefit in terms of your coronary heart disease, but you also lose weight, your metabolism improves, your blood pressure regulates itself, your risk of cancer minimises, you enhance your performance and your quality of life - it's a colourful bouquet of positive things.\u0026rsquo; (HA_FG_03, GP A)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1b\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lsquo;If we know which four risk factor constellations are the ones that influence our morbidity the most, that is nicotine, alcohol, lack of physical activity, and malnutrition.\u0026rsquo; (HA_FG_02, GP F)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1c\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lsquo;I would also find that interesting: are there any figures on how much physical activity minimises the risk, how much physical activity do I need?\u0026rsquo; (HA_FG_01, GP A)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eConceptualisation of PA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lsquo;I mean, they don't need to become top athletes, but physical activity is important. It's really not just young people, but also older individuals who need to stay active, not just sit in front of the TV and become sedentary. The goal is to improve their quality of life.\u0026rsquo; (HA_Int_01)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2b\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lsquo;What I emphasize here is that it's not about doing high-performance sport, but about saying that any kind of physical activity is good, e.g. walking the dog is just as effective as cycling or swimming, so we should take the focus off performance[\u0026hellip;] and instead highlight the opportunities for everyday activity.\u0026rsquo; (HA_Int_08)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2c\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lsquo;If you then engage in sports, you have to do endurance training, otherwise it won't be as effective.\u0026rsquo; (HA_Int_02)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2d\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lsquo;In discussions with CHD patients, there is of course also the age limit, yes? From a certain age, sport is simply no longer plausible for them, right? It\u0026acute;s no longer part of it.\u0026rsquo; (HA_FG_05, GP A)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e*The analysis of the study is based on the original German transcripts. Quotations were subsequently translated and reviewed by two other researchers. However, every translation is also an interpretation, due to cultural and regional specific language.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eNeeds and requirements for a training concept on brief PA counselling\u003c/h2\u003e \u003cdiv id=\"Sec12\" class=\"Section3\"\u003e \u003ch2\u003eContent-related needs and requirements\u003c/h2\u003e \u003cp\u003eNearly all participating GPs emphasised the need for peer exchange on advising patients about PA. Such exchange was valued for providing mutual support on daily practice, including assistance with expressing professional concern and interest about patients\u0026rsquo; health effectively, and enhancing skills in motivational interviewing (quote 1a, Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSome GPs also highlighted the value of guided self-reflection, e.g., through a peer trainer. Identified areas for reflection included the role and attitudes of GPs towards providing PA advice, the importance of PA advice by GPs, the omission of PA discussions in patient consultations, target groups and individuals who receive less advice (and the reasons for this), and GPs own PA behaviour (quote 1b and c, Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe majority of participating GPs mentioned a strong need for information on evidence-based knowledge on health-beneficial effects of PA in general, in patients with CHD (e.g., compared to drug therapy), on specific PA recommendations for CHD (e.g., frequency, intensity), and on the effectiveness of GP advice on PA (quote 1d and e, Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Few GPs asked for instructions on how to assess a patient's PA history and current PA behaviour (quote 1f, Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eLow-threshold and timesaving communication techniques for PA advice were also required from some of the participating GPs as a central aspect of a training on PA advice (e.g., conversation guides, motivational interviewing, brief advice approaches) (quote 1g, Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). In this regard participating GPs also noted specific concerns, such as overly structured discussions that may not align with empathetic and patient-centred conversations between GPs and patients, particularly in the context of long-standing patient-physician relationships. In contrast, few of the participating GPs did not express a need for further knowledge on beneficial effects of PA in CHD or on advising patients on PA. In these cases, sufficient knowledge or a higher priority on peer exchange were given as reasons (quote 1h, Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSome participating GPs expressed the need for support materials which could be used during conversations with their patients on PA or to be passed on to patients, including visualisations of evidence-based knowledge on the effectiveness of PA in CHD, PA recommendations on frequency and intensity, patient-friendly information material on specific and low-threshold (digital) PA recommendations, a compilation of regional PA programmes for individuals with CHD, and information on reimbursement options or financial subsidies for PA programmes (e.g., from health insurance companies) (quote 1e and j, Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eDidactic-related needs and requirements\u003c/h2\u003e \u003cp\u003eThe participating GPs agreed that all training content should be low-threshold, practical, directly implementable, and tailored to their specific needs (quote 2a, Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Interactive training formats were seen as particularly beneficial, with elements that support these formats \u0026ndash; such as small group sizes and a trusting atmosphere \u0026ndash; being highly valued.\u003c/p\u003e \u003cp\u003eRole plays with simulation patients (brought in by the participating GPs) were seen as effective by few participating GPs when teaching communication techniques, but were largely rejected by most of the participating GPs. A main reason seems to be that acting in front of peers is perceived as intimidating and unpleasant (quote 1i, Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eNotably, GPs expressed interest in incorporating PA into the training itself, such as through PA breaks. They suggested that experiencing the immediate effects of PA could enhance their self-awareness and motivation to provide PA advice. Additionally, some GPs proposed exercises from rehabilitation or cardiac sports programmes that could be directly recommended to patients (quote 2b and c, Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eVery few GPs expressed a need for an interdisciplinary or interprofessional training approach. Their suggestions ranged from including sports science or physical therapy expertise to designing a multiprofessional training programme involving other HPs, such as medical assistants or physiotherapists (quote 2d, Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eOrganisation-related needs and requirements\u003c/h2\u003e \u003cp\u003eThe preferred training format for GPs varied including online, blended learning, or face-to-face formats, and seemed to be strongly influenced by their experiences with previous training and personal factors, such as commitments to their practice or family, or long travel distances to the training location from more rural areas. However, for the majority of GPs, the format of the training did not seem to be a determining factor for their final participation (quote 3a, Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMost GPs welcomed the integration of a training on advising CHD patients on PA into existing formats, such as mandatory vocational or continuing medical education in disease management programmes or group discussion meetings within GP networks (quote 3b, Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eQuotations of the main category \u0026lsquo;Requirements and needs for training concept\u0026rsquo; organised by subcategories (translated from German into English*)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSubcategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eQuote No.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eQuotation\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"9\" rowspan=\"10\"\u003e \u003cp\u003e\u003cb\u003eContent-related\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lsquo;That you simply enter into a discussion with colleagues based on a specific topic or a keynote speech and then openly exchange experiences: Does it help? What experiences have you had with it? These are actually the events where you're most likely to take something away afterwards or feel validated in the way you do things.\u0026rsquo; (HA_Int_09)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1b\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lsquo;How do we actually manage to talk about the potential for change? This involves self-motivation, external motivation, and incentives. And for me, this is closely linked to the topic of physical activity. And if you ask me, that\u0026acute;s actually part of it. What actually prevents us, what makes us resign ourselves in advising or with patients?\u0026rsquo; (HA_FG_05, GP C)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1c\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lsquo;What does physical activity mean to me? Why do I think my patients don't exercise? Why don't I address this?\u0026rsquo; (HA_Int_08)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1d\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lsquo;What impact does physical activity have compared to, for example, statin therapy in patients who already have CHD? Having a good data basis for this.\u0026rsquo; (HA_Int_08)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lsquo;What I would find helpful is clear information on the topic: What is evidence-based with regard to CHD and physical activity? What is supported by reliable data that you can give people in a reproducible and reliable way?\u0026rsquo; (HA_Int_12)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1f\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lsquo;How can I find out from the patient what they do and what they don't do? [...] How can I find out where they actually stand through dialogue or a brief intervention?\u0026rsquo; (HA_FG_05, GP A)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1g\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lsquo;It's communication training. It\u0026acute;s about improving communication so that I can motivate the patient and this may also involve experiencing positive examples of inner attitudes towards the patient so that the conversation is successful and the patient is then able to implement physical activity.\u0026rsquo; (HA_Int_07)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1h\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lsquo;It's about talking about, seeing, and hearing what colleagues say or advise in certain situations. It's not about acquiring new cognitive knowledge. I think that's obvious, everyone knows it, everyone has it at hand.\u0026rsquo; (HA_Int_10)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1i\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lsquo;So, the training sessions that I benefited from also involved roleplays [...] of course that's a super uncomfortable situation, you don't really want to be in it, but it's incredibly useful [...] when you're sitting there uninvolved and then: Hmm, why isn't the colleague engaging with this? But I also found it very helpful to see how certain things caused a reaction and to really experience that. I was able to take a lot with me back then, I don\u0026acute;t want to say that I always manage it, but I really took a few key things with me and found it extremely helpful.\u0026rsquo; (HA_FG_04, GP B)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1j\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWhat would appeal to me would be exercise programmes that are easy to implement, simple tips on that. There are also sports programmes that are not very well-known, but which would be good to find out more about what options are available.\u0026rsquo; (HA_Int_06)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eDidactic-related\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lsquo;It's great to be at a new level here. Especially, as I said, whenever it\u0026acute;s suitable for everyday use, when I think: I can put it into practice like this.\u0026rsquo; (HA_Int_04)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2b\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lsquo;An exercise program, a kind of take-away effect, something that is exciting for you, so that you don\u0026acute;t just learn: What can I do for other people? But also gaining something good for yourself. For me personally, for example, it would be great to have something like yoga in the evening, I think that would be nice. If you could combine that with a practical part and do something like that.\u0026rsquo; (HA_Int_08)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2c\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lsquo;What I would really be interested in is: What do they do in the cardiac exercise groups, and what does it look like? What do they do right, and what might they be doing wrong? It would be helpful to actually experience it, maybe even taking part in a session yourself. Then you realise what you can recommend to patients and what not.\u0026rsquo; (HA_Int_12)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2d\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026acute;Also, to talk to sports scientists or something, so it's not just one-sided from the medical perspective, but also includes input from other areas, from physiotherapy, for example.\u0026rsquo; (HA_Int_01)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eOrganisation-related\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lsquo;But apart from that, I very rarely go to training courses. So I do it in writing at home.\u003c/p\u003e \u003cp\u003eI: What exactly stops you from doing that?\u003c/p\u003e \u003cp\u003eP: [exhales] Very practically: I have a wife who works full time three children at home.\u0026rsquo; (HA_Int_11)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3b\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lsquo;So not an additional event on top of the existing DMP obligations, because that often requires a lot of time and effort anyway. But within the framework of these training course, it would be good to say: Okay, this is a simple tool for the care of CHD patients, because it is inexpensive, low-effort and can be customised. \"\u0026rsquo; (HA_Int_08)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e*The analysis of the study is based on the original German transcripts. Quotations were subsequently translated and reviewed by two other researchers. However, every translation is also an interpretation, due to cultural and regional specific language.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003ePrincipal findings\u003c/h2\u003e \u003cp\u003eThe present study focusses on German GPs\u0026rsquo; target-group specific needs and requirements regarding content, organisation and didactics towards a training on PA advice to their patients as well as on their knowledge about and conceptualisations of PA and of PA in CHD patient care. Together with results from our earlier work,(\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e) we aim to inform the design of a target-group oriented GP training in the effective and efficient provision of advice on PA during routine consultations with CHD patients.\u003c/p\u003e \u003cp\u003eOur findings show that most participating GPs have general knowledge of the health beneficial effects of PA (e.g., minimising the risk of cancer, impact on quality of life). However, with regard to knowledge on specific PA recommendations for patients with CHD in terms of type, intensity, concrete PA recommendations, or proven effects on CHD management, GPs express the need for more evidence-based information.\u003c/p\u003e \u003cp\u003eWe do not find a consistent conceptualisation of PA in the context of preventive medicine. While some GPs incorporate the idea of everyday exercise \u0026ndash; an approach proven to be beneficial and adaptable for diverse patients \u0026ndash; this does not seem to be widely applied. In contrast, a few recommendations focus on performance-oriented or institutionalised approaches to PA, such as the recommendation of cardiac sports groups. This highlights an opportunity to emphasise and train GPs on the importance of everyday activity, underscoring the concept that \u0026acute;every step or every minute counts\u0026acute;.(\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eOur findings show a clear need for peer exchange and reflection on PA in the care of patients with CHD and in advising patients on PA. Some GPs lack a clear understanding of how to provide effective and efficient PA advice or counselling. The need for peer exchange could be driven by factors such as the desire for feedback and validation of their approach to discussing PA with patients, as well as fostering a positive attitude and role in promoting PA and related advice. Allocating some time for a structured dialogue \u0026ndash; facilitated by a peer trainer who poses reflective questions and introduces accessible methods for advising on PA \u0026ndash; could address these needs effectively.\u003c/p\u003e \u003cp\u003eWhen it comes to specific didactics and organisational aspects of training in the provision of PA advice, GPs outline relatively detailed, practical, and realistic requirements. These include low-threshold, practically relevant, and directly implementable training content that address their specific needs. They also emphasised the importance of support materials on PA, both for their own use and to share with patients. Considering the unique context of GP care \u0026ndash; such as the longstanding patient-physician relationship \u0026ndash; and ensuring the practical relevance of training content seem to be crucial to its acceptance.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eComparison with existing literature\u003c/h2\u003e \u003cp\u003eGPs\u0026rsquo; lack of education and training may contribute to gaps in knowledge and skills, as well as to unsatisfactory experiences in providing PA advice to patients.(\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e) However, to the best of our knowledge, there are no qualitative studies in Germany that have investigated in depth the knowledge and conceptual understanding of PA in the context of CHD patient care among GPs, as well as the content, organisational, and didactic requirements for a GP training on PA advice.\u003c/p\u003e \u003cp\u003eSome quantitative studies have examined GPs\u0026rsquo; knowledge and competence regarding various health aspects, including the frequency of PA advice.(\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e) For example, a German study that about the promotion of PA among older adults found that physicians (n\u0026thinsp;=\u0026thinsp;60, including 48 GPs) rated their knowledge about PA and their skills in initiating and advising on PA at an intermediate level.(\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e) A study from the United Kingdom concluded that 80% of GPs were unfamiliar with the national PA guidelines.(\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eOur findings on knowledge partially align with those of a qualitative study conducted in Ireland, which used semi-structured online interviews with HPs.(\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e) Although the majority of the 63 participants were not GPs (only 16%) the participants recognised the general benefit of PA and demonstrated knowledge of specific areas, such as fall prevention.(\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e) Despite methodological differences to our study, the Irish study\u0026rsquo;s insights into the support HPs need to deliver effective and efficient PA advice are consistent with our results. The HPs interviewed expressed the need for tailored educational opportunities, emphasising brief, practical training sessions grounded on real-life scenarios and simulated GP consultations.(\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eParallels can also be drawn with the above mentioned German questionnaire survey in physicians, where they were asked about preferred types of information and training formats.(\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e) The majority of participants (n\u0026thinsp;=\u0026thinsp;38/60) favoured a short seminar, while 27 participants expressed interest in a brief self-administered intervention, and 37 participants were interested in patient materials.(\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e) Participants in another German qualitative study about health promotion in primary care highlighted the preference for digitally accessible, innovatively designed informational materials, along with an overview of where to find information on specific topics.(\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eOther studies from the UK, Canada and Finland have proposed training concepts for advising patients on PA.(\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e) In most cases, the training components \u0026ndash; such as assessing patients\u0026rsquo; PA level, using motivational interviewing techniques to promote PA, and providing written PA instructions \u0026ndash; are derived from quantitative studies.(\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e) These studies underscore a lack of training, knowledge, or tools for prescribing PA (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e). However, it remains unclear to what extent the developed training programmes are grounded in the findings of these studies.(\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eNotably, some components of these developed trainings overlap with those mentioned by the GPs we interviewed, such as the peer-to-peer approach.(\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e) This highlights the importance of integrating evidence-based strategies with practical, context-specific elements when designing training programmes for PA advice.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and weaknesses of the study\u003c/h2\u003e \u003cp\u003eThe continuous involvement of the target group in the development of interview guides, analysis and interpretation of the data is the main strength of this qualitative study. Results were thus consistently reviewed and validated from individuals with different perspectives. In addition, all data were double-coded (primary and control), which contributes to the quality of the coding process and findings following from those.\u003c/p\u003e \u003cp\u003eThe study also has limitations. GPs who agreed to participate might more likely have an interest in providing lifestyle and PA advice, which may have motivated them to share their experiences. Furthermore, their personal interests could have also influenced their shared experiences. In order to still capture a diverse range of GPs and their perspectives (e.g., in terms of professional experience, practice location, and interest in PA), and to minimise the potential selection bias, we used multiple sampling strategies: For focus group discussions, we aimed to include all GPs of a GPs network, which may have increased the chance to include also GPs less interested in lifestyle counselling. However, GPs networks also attract specific characters, such as individuals particularly interested in sharing and learning from colleagues.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis qualitative study provides detailed insights into German GPs knowledge of PA and conceptualisations of PA in the context of caring for patients with CHD, as well as their content, didactic, and organisational needs for a training on the routine delivery of PA advice to these patients. Combined with our earlier analysis of their experiences, perceptions, and attitudes towards PA and towards advising on PA (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e), these findings are essential for systematically developing a tailored training designed to positively influencing GPs\u0026rsquo; practices in advising CHD patients on PA.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCOREQ Consolidated Criteria for Reporting Qualitative Research\u003c/p\u003e\n\u003cp\u003eDMP Disease Management Programme\u003c/p\u003e\n\u003cp\u003eGP General practitioner\u003c/p\u003e\n\u003cp\u003eHP Health professional\u003c/p\u003e\n\u003cp\u003eCHD Coronary heart disease\u003c/p\u003e\n\u003cp\u003eNCDs Non-communicable diseases\u003c/p\u003e\n\u003cp\u003eNRW North-Rhine-Westphalia \u003c/p\u003e\n\u003cp\u003eOSF Open Science Framework\u003c/p\u003e\n\u003cp\u003ePA Physical Activity\u003c/p\u003e\n\u003cp\u003eWHO World Health Organization \u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the ethics committee of Heinrich-Heine-University D\u0026uuml;sseldorf, Germany (2022-2237, 06.03.2023).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data relevant to the study are included in the article or uploaded as online supplemental information.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAP, SH, RC and SW have no competing interests to declare. SK has received public funding from the German Ministry of Education and Research (BMBF) to conduct the study, although the funder is not involved in the design, analyses, or reporting of the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe OptiCor project has been funded as a junior research group in health services research by the German Ministry of Education and Research (BMBF) (funding period: 05/2022-04/2027, grant number: 01GY2103).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026acute; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAP drafted the manuscript and conducted all preparatory work for the study. SK conceived of the study, acquired funding for the study, co-wrote this paper, and supervised all preparatory work. RC and SW participated in the design of the study. AP, SH and SK interpreted the data. All named authors contributed substantially to the manuscript and agreed on its final version. All authors read an approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors gratefully acknowledge the time given by the GPs who participated in this study. We would like to thank Angela Fuchs (psychologist) and Lisa Gummersbach (GP) for the conduction of some of the focus group discussions, Franziska Vogl (student assistant) and Gabriele Franken (GP) for their support with the control coding, Leonie Bamberg (student assistant) for the translation of the quotations and Olaf Reddemann (GP) and Verena Leve (sociologist, researcher) for their support during the analysis.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eDibben GO, Faulkner J, Oldridge N, Rees K, Thompson DR, Zwisler AD, et al. 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Health promotion in primary care: How should we intervene? A qualitative study involving both physicians and patients. \u003cem\u003eBMC Health Services Research\u003c/em\u003e. 2011;11(1):62.\u003c/li\u003e\n\u003cli\u003eAlbert FA, Crowe MJ, Malau-Aduli AEO, Malau-Aduli BS. Physical Activity Promotion: A Systematic Review of The Perceptions of Healthcare Professionals. \u003cem\u003eInt J Environ Res Public Health\u003c/em\u003e. 2020;17(12):4358.\u003c/li\u003e\n\u003cli\u003eWattanapisit A, Thanamee S, Wongsiri S. Physical activity counselling among GPs: a qualitative study from Thailand. \u003cem\u003eBMC Family Practice\u003c/em\u003e. 2019;20(1):72.\u003c/li\u003e\n\u003cli\u003eCunningham C, O\u0026apos;Sullivan R. Healthcare Professionals\u0026apos; Application and Integration of Physical Activity in Routine Practice with Older Adults: A Qualitative Study. Int J Environ Res Public Health. 2021;18(21).\u003c/li\u003e\n\u003cli\u003ePhysical activity: brief advice for adults in primary care. Public health guideline. National Institute for Health and Care Excellence (NICE); 2013.\u003c/li\u003e\n\u003cli\u003ePrinz A, Hoppe S, Leve V, al. e. Experiences, perceptions and attitudes on providing advice on physical activity to patients with chronic ischemic heart disease \u0026ndash; A qualitative study in general practitioners in Germany, 23 July 2024. PREPRINT (Version 1) Available at Research Square [https://doiorg/1021203/rs3rs-4777870/v1].\u003c/li\u003e\n\u003cli\u003eWilliams SJ, Calnan M. Perspectives on prevention: the views of General Practitioners. \u003cem\u003eSociology of Health \u0026amp; Illness\u003c/em\u003e. 1994;16(3):372-93.\u003c/li\u003e\n\u003cli\u003eHoppe S, Prinz A, Crutzen R, Donner-Banzhoff N, Icks A, Kotz D, et al. Optimising the treatment of chronic ischemic heart disease by training general practitioners to deliver very brief advice on physical activity (OptiCor): protocol of the systematic development and evaluation of a complex intervention. BMC Primary Care. 2024;25(1):404.\u003c/li\u003e\n\u003cli\u003eTong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. \u003cem\u003eInternational journal for quality in health care\u003c/em\u003e. 2007;19(6):349-57.\u003c/li\u003e\n\u003cli\u003eWitzel A. The Problem-Centered Interview [Das problemzentrierte interview]. \u003cem\u003eForum Qualitative Sozialforschung Forum: Qualitative Social Research\u003c/em\u003e. 2000;1(1):22.\u003c/li\u003e\n\u003cli\u003eSchulz M, Mack B, Renn O. Focus groups in empitical social science: from conception to evaluation [Fokusgruppen in der empirischen Sozialwissenschaft: Von der Konzeption bis zur Auswertung]. 1 ed. Wiesbaden: VS Verlag f\u0026uuml;r Sozialwissenschaften Wiesbaden; 2012. 209 p.\u003c/li\u003e\n\u003cli\u003eBohnsack R, Przyborski A, Sch\u0026auml;ffer B. The group discussion procedure in research practice [Das Gruppendiskussionsverfahren in der Forschungspraxis]. Opladen: Budrich; 2006.\u003c/li\u003e\n\u003cli\u003eKuckartz U. Qualitative content analysis. Methods, practice, computer suppport [Qualitative Inhaltsanalyse. Methoden, Praxis, Computerunterst\u0026uuml;tzung]. 3 ed. Weinheim, Basel: Beltz Juventa; 2016.\u003c/li\u003e\n\u003cli\u003ePatton MQ. Qualitative evaluation and research methods, 2nd ed. Thousand Oaks, CA, US: Sage Publications, Inc; 1990. 532- p.\u003c/li\u003e\n\u003cli\u003eVERBI Software. MAXQDA 2022.\u003c/li\u003e\n\u003cli\u003eBanach M, Lewek J, Surma S, Penson PE, Sahebkar A, Martin SS, et al. The association between daily step count and all-cause and cardiovascular mortality: a meta-analysis. Eur J Prev Cardiol. 2023;30(18):1975-85.\u003c/li\u003e\n\u003cli\u003eMoving Medicine. Increase walking. 12-week PACE-UP programme to help you increase your walking. 2020. Available at https://movingmedicine.ac.uk/wp-content/uploads/sites/5/2022/04/PACE-up-MM-edit-v92.pdf.\u003c/li\u003e\n\u003cli\u003eMcPhail S, Schippers M. An evolving perspective on physical activity counselling by medical professionals. BMC Family Practice. 2012;13(1):31.\u003c/li\u003e\n\u003cli\u003eBuckley BJR, Finnie SJ, Murphy RC, Watson PM. \u0026quot;You\u0026apos;ve Got to Pick Your Battles\u0026quot;: A Mixed-Methods Investigation of Physical Activity Counselling and Referral within General Practice. Int J Environ Res Public Health. 2020;17(20).\u003c/li\u003e\n\u003cli\u003ePeters S, Schwab M, Faller H, Meng K. Training for physicians for physical activity promotion in older adults [Schulung f\u0026uuml;r \u0026Auml;rzte zur Bewegungsf\u0026ouml;rderung bei \u0026Auml;lteren]. \u003cem\u003ePr\u0026auml;vention und Gesundheitsf\u0026ouml;rderung\u003c/em\u003e. 2017;12(3):218-26.\u003c/li\u003e\n\u003cli\u003eCunningham C, R OS. Healthcare Professionals\u0026apos; Application and Integration of Physical Activity in Routine Practice with Older Adults: A Qualitative Study. \u003cem\u003eInt J Environ Res Public Health\u003c/em\u003e. 2021;18(21):11222.\u003c/li\u003e\n\u003cli\u003eEngler J, Sch\u0026uuml;tze D, Gerber M, Dieckelmann M, Siebenhofer-Kroitzsch A. Field of action analysis of health promotion in the GP practice (GeHa) [Handlungsfeldanalyse Gesundheitsf\u0026ouml;rderung in der Hausarztpraxis (GeHa)]. Berlin: Health Knowledge Foundation [Stiftung Gesundheitswissen]; 2023.\u003c/li\u003e\n\u003cli\u003eWindt J, Windt A, Davis J, Petrella R, Khan K. Can a 3-hour educational workshop and the provision of practical tools encourage family physicians to prescribe physical activity as medicine? A pre-post study. BMJ Open. 2015;5(7):e007920.\u003c/li\u003e\n\u003cli\u003eAittasalo M, Kukkonen-Harjula K, Toropainen E, Rinne M, Tokola K, Vasankari T. Developing physical activity counselling in primary care through participatory action approach. BMC Fam Pract. 2016;17(1):141.\u003c/li\u003e\n\u003cli\u003eBrannan M, Bernardotto M, Clarke N, Varney J. Moving healthcare professionals - a whole system approach to embed physical activity in clinical practice. BMC Med Educ. 2019;19(1):84.\u003c/li\u003e\n\u003cli\u003eBrannan M, Hughes-Short M. The Moving Healthcare Professionals Programme. British Journal of General Practice. 2020;70(suppl 1):bjgp20X711341.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"German Ministry of Education and Research (BMBF) ","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Chronic ischemic heart disease, coronary heart disease, physical activity, general practice, primary care, qualitative research, brief intervention, brief counselling, education, training","lastPublishedDoi":"10.21203/rs.3.rs-6678811/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6678811/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e The World Health Organization and German treatment guidelines emphasise integrating physical activity (PA) advice into primary care of patients with coronary heart disease (CHD). \u0026nbsp;However, in general practice in Germany, this is often inadequately implemented. A key barrier may be healthcare professionals’ limited knowledge and skills in providing effective and efficient PA guidance. To address this, international guidelines recommend targeted training for general practitioners (GPs). Understanding GPs' specific educational and training needs is crucial to developing tailored training programmes for improving implementation of advising CHD patients on PA.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eBetween March and June 2023, 12 problem-centred one-on-one interviews and six moderated focus group discussions (n=37 participants) with GPs were conducted (total n=49 GPs). Interview and discussion guides were developed and pilot-tested by the multi-professional study team. Audio-recorded data were transcribed verbatim and analysed using a content structuring procedure (deductive and inductive approaches) within a multi-professional team, with active involvement of GPs.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eIn general, GPs recognise the benefits of PA for CHD patients. Their conceptualisations of PA (e.g., definitions of sport and PA, general statements on PA, on types of PA) vary and the incorporation of PA in everyday activities (e.g., using stairs) to encourage behaviour change is sometimes recommended. GPs identify the following key training needs for providing PA advice to CHD patients: peer exchange and self-reflection, evidence-based knowledge on PA and CHD, practical tools and support materials to facilitate the integration of PA advice into routine practice. These include low-barrier, time-efficient communication techniques, and role–play simulations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eBuilding on own previous findings about GPs' experiences, attitudes, and beliefs regarding PA advice, the now identified educational and training needs form a foundation for developing a tailored GP training on supporting CHD patients with regard to PA. This will be implemented and evaluated in a follow-up study.\u003c/p\u003e","manuscriptTitle":"General practitioners’ educational and training needs and requirements for advising patients with coronary heart disease on physical activity: Findings from a qualitative study in Germany","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-19 08:16:32","doi":"10.21203/rs.3.rs-6678811/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d48bb372-e13c-4383-b4eb-5d5906ee89bd","owner":[],"postedDate":"May 19th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":48623042,"name":"General Practice"}],"tags":[],"updatedAt":"2025-05-19T08:16:33+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-19 08:16:32","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6678811","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6678811","identity":"rs-6678811","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}