Investigating primary health care practitioners’ barriers and enablers to referral of COPD patients to Pulmonary Rehabilitation: an exploratory sequential mixed methods study using the Theoretical Domains Framework

Abstract BackgroundPulmonary rehabilitation is a highly effective, globally recommended intervention for patients with Chronic Obstructive Pulmonary Disease (COPD). Understanding why referral rates remain persistently low is important and enables the development of targeted interventions in order to improve future uptake. MethodsWe undertook an exploratory sequential mixed methods study to investigate the referral practices of Primary Health Care Practitioners (PHCPs) in the United Kingdom (UK). In phase 1 semi structured interviews were undertaken. Content analysis was used to map arising themes to the Theoretical Domains Framework (TDF) and the development of a 54-item TDF based questionnaire.In Phase 2 we distributed the questionnaire through relevant conferences and organisation memberships, to obtain views from a larger, more generalisable PHCP population. We used descriptive analyses to identify the most important barriers and enablers, and key TDF domains. Mixing of data occurred at 2 time points; instrument design and interpretation. Results19 PHCP took part in interviews and 233 responded to the survey. Integrated results revealed that PHCPs with a post qualifying respiratory qualification (154/241; 63.9%) referred more frequently (91/154; 59.1%) than those without (28/87; 32.2%).There were more barriers than enablers for referral in all 13 mapped TDF domains. Key barriers included: infrequent engagement from PR provider to referrer, concern around patient’s physical ability and access to PR (particularly for those in work), assumed poor patient motivation, no clear practice referrer and few referral opportunities. These mapped to the following domains: belief about capabilities, social influences, environment, optimism, skills and social and professional role.Enablers to referral were observed within the knowledge, social influences memory and environment domains. Many PHCPs believed in the physical and psychological value of PR, and helpful enablers were out-of-practice support from respiratory interested colleagues, dedicated referral time (annual review) and on-screen referral prompts. ConclusionsReferral to PR is a complex process. Barriers outweighed enablers. Aligning these findings to behaviour change techniques will identify practice-based interventions to overcome current barriers and strengthen enablers, thereby increasing referral of COPD patients to PR as recommended by international COPD guidelines