Barriers and Implementation strategies for Physical Activity on Prescription (PAP): Healthcare personnel and Management Perspectives in Sweden—An Explanatory Sequential Study Design

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Physical activity on prescription (PAP) is a recommended method for promoting physical activity in Swedish primary healthcare and in other European countries, but its implementation varies across regions. This study aimed to identify barriers and strategies to strengthen PAP implementation in a region with low prescription rates, as perceived by healthcare personnel and managers in primary healthcare. Methods A mixed-methods study with an explanatory sequential design was conducted (spring 2024) in a geographically dispersed region of Sweden. The digital surveys were completed by 75 healthcare personnel and 18 managers. Uni-, bi and multivariate analyses were used for quantitative data, followed by semistructured interviews (n = 14) analysed with qualitative content analysis, guided by normalization process theory (NPT). Results Thirteen percent of healthcare personnel prescribed PAP regularly. Physiotherapists prescribed PAP more often than other professionals did (odds ratio [OR] 4.0, confidence interval [CI] 1.01–15.83). Barriers included time constraints, lack of guidelines, knowledge and low managerial prioritization. Compared with those aged ≤ 45 years, personnel aged ≥ 46 years were more likely to perceive time constraints (OR 3.6, CI 1.27–10.16) when adjusted for gender and profession. Compared with males, females (n = 36/41, 88%) expressed more frequent trust in evidence for PAPs (n = 8/14, 57%), p = .013. Only 38% (n = 28) had received PAP training. Divergent perceptions between personnel and managers were noted regarding leadership engagement, personnel competence and patients’ receptiveness to PAPs. However, a majority expressed a desire to increase physical activity counselling. The areas of improvement included a shared understanding of PAPs, training, clear leadership and support structures, and systematic evaluation. Collaboration with activity providers and access to adapted patient materials were also identified as mitigating measures. Conclusions Strong interest in PAPs among healthcare personnel and managers indicates favourable conditions for sustainable implementation, provided that training to build a shared understanding and agreement around PAPs (coherence), customized resources and structured processes (cognitive participation), clear leadership commitments to facilitate allocated resources (collective action), and PAPs coordinated across organizational levels to support consistent monitoring and evaluation (reflexive monitoring) are all in place. Health promotion Healthcare Implementation Mixed-Methods design Normalization process theory Physical activity on prescription Primary healthcare Background Physical inactivity is a major contributor to the global burden of noncommunicable diseases (NCDs) and premature mortality [ 1 ]. The World Health Organization (WHO) attributed 20–30% of premature deaths to insufficient physical activity (PA) and estimated that 500 million preventable NCD cases may have occurred between 2020 and 2030 due to inactivity [ 1 ], with an associated annual healthcare cost of up to 27 billion US dollars [ 2 ]. Despite the WHO recommendations of 150–300 minutes of moderate PA per week [ 1 , 3 ], over 25% of adults globally—and 34% in Sweden—fail to meet this target [ 3 , 4 ]. Promoting PA is a core goal in both global and national health strategies and is a key component of Goal 3 of the UN’s Agenda 2030, which aims to ensure healthy lives and promote well-being for all ages [ 5 ]. In Sweden, PA is embedded in national public health goals related to lifestyle behaviours and health equity [ 6 ]. The Commission for Equity in Health [ 7 ] emphasized the need to strengthen individuals’ ability to promote health and prevent illness. The healthcare sector plays a central role in this effort, given its wide population reach and high credibility as a source of health information [ 8 ]. In 2021 alone, Swedish primary care records more than 36 million visits [ 9 ], highlighting its significant potential as an arena for preventive interventions. The National Board of Health and Welfare (NBHW) in Sweden recommends the use of physical activity on prescription (PAP) for patients at risk owing to low levels of PA [ 10 ]. The PAP model involves tailoring prescriptions to an individual’s health status, motivation, self-efficacy, and goals, with decisions guided by the severity of the condition and expected outcomes [ 10 ]. In 2001, PAP included individualized counselling, a written prescription, follow-up, and clinical guidance on the basis of the FYSS (Physical Activity in the Prevention and Treatment of Disease) handbook [ 11 ]. Collaboration with community-based activity providers is also encouraged. PAPs are currently implemented in all Swedish regions and are being adopted in other European countries [ 10 , 11 ]. Evidence indicates that PAP can increase PA levels, improve quality of life [ 12 – 15 ], and offer long-term health and economic benefits [ 16 ]. However, prescription rates remain inconsistent across regions [ 11 ], and PAPs are often viewed more as a secondary measure than as part of standard care and a routine practice [ 17 ]. Several barriers hinder effective implementation, including unfamiliarity with PAPs, limited knowledge of their evidence base and preventive role, lack of managerial support, insufficient training, unclear routines, and time constraints [ 11 , 18 , 19 ]. Differences in regional support structures, training opportunities, and professional networks contribute to unequal delivery across the country [ 20 ]. As with other complex interventions, the implementation of PAPs is highly context dependent. Conditions that promote success in one setting may be ineffective—or even counterproductive—in another [ 21 ]. Context encompasses both structural factors (e.g., staffing levels, geographic location) and social dynamics (e.g., routines, leadership, interprofessional relationships) [ 22 ]. Implementation processes can, in turn, reshape these dynamics [ 22 ], and sustained success depends on behaviour change at both the individual and organisational levels [ 8 ]. Normalization process theory (NPT) provides a valuable framework for studying the implementation of complex interventions [ 23 ]. It focuses on how new practices become embedded in everyday clinical work [ 24 , 25 ] through four interrelated constructs: (i) coherence—how participants understand and make sense of the intervention, including its relevance and purpose; (ii) cognitive participation—the level of engagement and commitment among actors to adopt and sustain the practice; (iii) collective action—the operational work required to implement the practice, including task distribution and collaboration; and (iv) reflexive monitoring—the process through which individuals and teams assess effectiveness and adapt practices over time [ 24 ]. Although PAPs are formally adopted by all 21 Swedish regions, decentralization has resulted in uneven implementation [ 11 ]. A sparsely populated region, located in mid-Sweden, has among the country’s lowest rates of PAP prescriptions [ 11 ]. Gaining a deeper understanding of barriers and facilitators in such underperforming contexts can inform more targeted and effective implementation strategies, both regionally and nationally. This study aimed to identify barriers and potential mitigation strategies to strengthen PAP implementation, as perceived by healthcare personnel and managers in a rural region where primary healthcare services are geographically dispersed. Methods This was a mixed-methods study with an explanatory sequential design [ 26 ] in a sparsely populated region in mid-Sweden during spring 2024. The quantitative survey data informed the subsequent qualitative interviews [ 26 ]. The study was carried out in collaboration between Mid Sweden University and the regional public health department, and the reporting adhered to the STROBE [ 27 ] and COREQ [ 28 ] guidelines. The study setting was Sweden’s third largest region by area, a sparsely populated region (~ 130,000 residents), with a mix of rural and urban communities [ 29 ]. Approximately one-third of the population lives in rural areas [ 30 ]. Healthcare services in this rural region are geographically dispersed, with limited staff and resources, and the long distances involved add further complexity to implementation efforts. Licenced healthcare personnel authorized to prescribe PAPs (e.g., physicians, nurses, physiotherapists) in primary healthcare settings, including a habilitation clinic and a day psychiatry clinic, and their managers participated. Surveys were distributed via internal channels and reached approximately 140 out of approximately 350 eligible personnel and 20 managers out of 36. Reminder emails and calls were used to increase response rates. At survey completion, participants could volunteer for interviews. Interview informants were recruited through digital questionnaires, where participants could provide their contact details if they consented to take part in individual interviews. This process yielded 14 informants (9 personnel members and 5 managers), representing a range of roles and settings. All participants in the questionnaire surveys received written information about the study and its aim. Consent was obtained through completion of the questionnaire. Those who agreed to participate in interviews received both written and verbal information and provided informed consent. Two structured online surveys were developed via Qualtrics software [ 31 ], a digital survey tool, one for healthcare personnel (36 items) and one for managers (16 items). The items included Likert scales, multiple-choice questions, and optional free-text responses. The surveys were refined through feedback from pilot testers (n = 13) and regional stakeholders. Of those reached, 75 personnel and 18 managers completed the surveys, yielding response rates of 54 percent and 90 percent, respectively. Semistructured interviews were conducted with 14 volunteers via Microsoft Teams, which lasted between 32 and 43 minutes, with one exception in which the respondent was interrupted by work, resulting in a shorter duration of 21 minutes. The interviews were recorded, transcribed verbatim, and guided by the four domains of the NPT [ 23 , 24 ]. Five interviewees also reviewed a summary of the preliminary survey results. The quantitative data were analysed via SPSS (v29) via descriptive statistics, such as Pearson’s chi-square test, Fisher’s exact test, and binary logistic regression with odds ratios (ORs) and confidence intervals (CIs). A significance level of p < .05 was applied throughout. Qualitative data, including interview transcripts and open-ended survey responses, were analysed deductively via content analysis [ 32 ]. The analysis began with an initial reading of the transcripts to familiarize them with the data, after which meaning units were identified and coded according to the NPT constructs [ 23 , 24 ]. Coding was performed by DS and then secondarily by MM. Discussions with the AM, AH, and TA were held to enhance credibility and ensure intercoder consistency, and discrepancies were resolved through further discussion. The interdisciplinary research team included members with backgrounds in public health, medicine, nursing, habilitation, and geography. All the participants shared an interpretivist orientation and viewed healthcare as a complex adaptive system (CAS), recognizing that implementation efforts are influenced by dynamic interactions between system actors and contextual factors [ 21 , 22 ]. Reflexive notes were kept throughout to support transparency. Results The survey was completed by 93 participants, comprising 75 healthcare personnel and 18 managers, where a majority were women (75%), representing diverse professional backgrounds (Table 1 ). Table 1 Survey respondent characteristics. Gender n % Female 70 75.3 Male 20 21.5 Nonbinary/do not wish to disclose 3 (1/2) 3.2 Age (healthcare personnel only) 20–35 14 18.7 36–45 23 30.6 46–55 22 29.3 55+ 16 21.3 Profession Physiotherapist 27 29.0 Nurse 20 21.5 Doctor 15 16,1 Occupational therapist 5 5.4 Other 4 4,3 Manager 18 19.4 Years in Current Profession (healthcare personnel only) 1–10 24 32.0 11–20 32 42.6 21+ 19 25.3 Unit (healthcare personnel only) Regional health centre 41 54.6 Private health centre 9 12.0 Psychiatry 19 25.3 Habilitation (adult/child) 6 8.0 Unit (managers) Regional health centre 14 77.8 Psychiatry and habilitation 4 22.2 While 77% of personnel reported providing basic PA advice regularly, only 13% prescribed PAPs monthly or more. Documentation of PAPs in medical records via Classification of Health Care Interventions Codes [KVÅ] was rare (Table 2 ). Table 2 Healthcare Personnel’s SelfReported Use of PAP Components. How often do you provide basic advice on PA? (n = 75) n % Daily 35 46.7 Once or a few times per week 23 30.7 A few times per month 9 12.0 A few times per year or never 8 10.7 How often do you provide counselling about PA? (n = 72) Daily 14 15,1 Once or a few times per week 23 24,7 A few times per month 21 22,6 A few times per year or never 14 15,1 How often do you prescribe PAP? (n = 72) Daily 1 1,1 Once or a few times per week 0 - A few times per month 11 11,8 A few times per year or never 60 64,5 Are patients who receive a PAP prescription followed up? (n = 75) Yes, usually 25 26,9 Rarely, or never 10 10,8 I do not prescribe PAP 40 43,0 Documentation in the medical record - Basic advice (n = 74) Always/often 4/9 5,4/12,1 Rarely/never 16/45 21,6/60,8 Documentation in the medical record – Counselling (n = 74) Always/often 2/7 2,7/9,4 Rarely/never 15/50 20.2/67.5 Documentation in the medical record [KVÅ*] - Qualified counselling (n = 74) Always/often 3/7 4.0/9.4 Rarely/never 18/46 24.3/62.1 Documentation in the medical record [KVÅ*] - PAP (n = 74) Always/often 9/5 12.1/6,7 Rarely/never 10/50 13.5/67.5 Documentation in the medical record [KVÅ*] – Follow up on PAP (n = 74) Always/often 7/6 9,4/8,1 Rarely/never 9/52 12.1/70.2 * Classification of Health Care Intervention Codes [KVÅ] Bivariate analysis revealed associations between age and PAP prescription. Older personnel (36+) were more likely to provide basic advice than younger personnel (20–35 years), whereas younger personnel were more likely to prescribe PAPs (Additional file 1). However, physiotherapists were more likely to prescribe PAP than other professionals were adjusted for age (OR 4.0, CI 1.01–15.83) (Table 3 ). Table 3 Binary logistic regression of PAP prescription by age and profession (n = 72). Independent variables B Sig. OR 95% CI Lower Upper Age: 20–35 Ref: 36+ 1.18 .111 3.25 .763 13.84 Physiotherapists * 1,.9 .048 4.0 1.01 15.83 *Ref: Other professions Perceived Competence in PAPs Self-reported competence in prescribing PAPs varies among healthcare personnel. While the vast majority of the participants felt confident in providing basic advice or counselling, 50% rated their competence in prescribing PAPs as low or very low (Additional file 2). Compared with other professionals, physiotherapists reported higher levels of competence in components of PAP, such as PA counselling and follow-up, and they also more frequently documented using classification codes of health care measures (Additional file 3). Few personnel had received PAP training (38%, n = 28), and 69% (n = 52) were unaware that training had previously been offered. A majority of the personnel lacked access to guidance or support materials in their daily work, and 81% (n = 61) were unaware of the national short version of the PAP guidelines for clinics. Perceived Barriers PAP work consists of multiple components and is accompanied by various challenges, as demonstrated by the barriers identified in Table 4 . Time constraints and a lack of guidelines were the two main barriers in both groups. Among the personnel, this was followed by a lack of knowledge among personnel and management, whereas the manger reported the unclear purpose of PAPs and that patients do not want to have PAPs. While perceived time constraints were commonly reported, a binary logistic regression indicated that personnel aged ≥ 46 years, compared with those aged ≤ 45 years, were more likely to perceive time constraints as barriers to PAP (OR 3.6, CI 1.27–10.16) when adjusted for gender and profession. Table 4 Healthcare Personnel’s Perceived Barriers and Suggested Implementation Measures for PAP Adoption Perceived barriers and mitigating strategies Total (N = 93) Healthcare personnel (n = 75) Managers (n = 18) Fisher’s exact test Barriers : n (%) n (%) n (%) Perceived time constraints 49 (52.6) 41 (54.6) 8 (44.4) .60 Lack of guidelines on PAP procedures et cetera within the region 45 (48.4) 38 (50.7) 7 (38.9) .437 Lack of knowledge among healthcare personnel 40 (43.0) 37 (49.3) 3 (16.7) . 016 Lack of knowledge/interest from management 36 (38.7) 34 (45.3) 2 (11.1) .007 Unclear purpose of PAP 24 (25.8) 17 (22.7) 7 (38.9) .228 Patient not receptive to/do not want PAP 21 (22.6) 15 (20.0) 6 (33.3) .227 Lack of financial incentives 14 (15.0) 12 (16.0) 2 (11.1) 1.0 Technical barriers 7 (7.5) 7 (9.3) 0 (-) .339 I have no opinion 9 (9.7) 7 (9.3) 2 (11.1) 1.0 Potential mitigating strategies Educate more healthcare personnel in the PAP method 54 (58.0) 48 (64.0) 6 (33.3) .031 Increase knowledge about PA/PAP among the population 41 (44.0) 32 (42.7) 9 (50) .606 Management needs to prioritize PAP 35 (37.7) 32 (42.7) 3 (16.7) .041 Improve access to information about PAP for personnel (e.g. on the region's website) 35 (37.7) 29 (38.7) 6 (33.3) .790 Increased collaboration on PAP 27 (29.0) 22 (29.3) 5 (27.8) 1.0 Simplify the systems (such as documentation) 25 (26.9) 22 (29.3) 3 (16.7) .380 Possibility to delegate follow-up of PAP to someone other than prescriber 22 (23.6) 20 (26.7) 2 (11) .224 Financial incentives for PAP 22 (23.6) 16 (21.3) 6 (33.3) .355 I have no opinion 8 (8.6) 4 (5.3) 4 (22.2) .043 Potential Mitigating Strategies The most frequently suggested mitigating measure to improve PAP work was to educate more healthcare personnel on this method (Table 4 ). It was proposed by 64% of personnel but only 33% of managers. Personnel were also more likely than managers to cite the need for management to prioritize PAPs (43% vs. 17%). Approximately half of both personnel and managers highlighted the need to raise public awareness of PAPs. Additionally, approximately one-third of both groups emphasized the need to improve personnel access to information about PAPs and to enhance collaboration in their implementation (Table 4 ). An additional finding was that over half of healthcare personnel (52%, n = 39) expressed a need for improved patient materials in plain Swedish for groups requiring them, and 59% (n = 44) also wanted materials available in other languages. A large majority (80%, n = 60) highlighted the need for collaboration with community activity providers, such as gyms and sports clubs, whereas 84% (n = 63) believed that a consolidated list of home-based activity suggestions would support PAP work. Over half of the respondents reported confidence in the method’s potential, both as an effective treatment method and to promote health (Table 5 ). However, about a third stated they had no opinion, and a small share argued that evidence was poor or very poor. Compared with male personnel (n = 8/14, 57%), female personnel were more likely (n = 36/41, 88%) to express trust in evidence for PAP as an effective treatment method or as part of treatment for certain diseases (p = .013). Table 5 Perceptions of Research Evidence for PAPs as a Trust Method. Evidence for PAP as an effective method to promote health (healthcare personnel and managers, n = 93) N % Very strong evidence/Strong evidence 9/41 9.7/44.1 Very poor evidence/Poor evidence 10/3 10.8/3.2 No opinion 28 30.1 Evidence for PAP as an effective treatment method/part of treatment (healthcare personnel and managers. n = 93) Very strong evidence/Strong evidence 7/39 7.7/42.8 Very poor evidence/Poor evidence 8/3 8.8/3.3 No opinion. 34 37.4 Despite the identified barriers and the low number of PAP prescriptions 69% (n = 50) of healthcare personnel expressed a desire to increase their involvement in physical activity counselling. Similarly, 75% (n = 12) of managers wanted their staff to work more with PA counselling. Qualitative findings The qualitative analysis began by categorizing the open-ended responses from the survey into the NPT domains. An example of how the responses were sorted is shown in Additional file 4. The overall findings from the qualitative analysis revealed four themes (Table 6 ). Table 6 Qualitative Themes Illustrating Barriers to PAP Work and Corresponding Implementation Solutions (healthcare personnel = 9; managers = 5). Domain of NPT Code Category Theme Coherence Strong/poor evidence for PAP Lack of consensus regarding PAP as a method Need for legitimacy-building training activities that create consensus Meeting patient expectations Lack of anchoring in scope of practice/Statutory role description Lack of formal responsibility Responsibility Cognitive participation Praxis norms vary Generalization and short-sightedness Need for adapted materials and routines to foster engagement and participation Need for adapted routines and guidelines Projects hinder long-term implementation Health information/education “It takes two to tango” in patient encounter Sense of competence Collective action Systematization and formalization Structural organization Need for clear leadership and resources for a collectively sustainable PAP work Cross-sector collaboration Financial incentives Finding the right tools and support Motivation-building Overcome time- and resource shortages Support resources Technical solutions Reflexive monitoring/evaluation Heterogeneous group working across various healthcare settings Unsynchronized PAP work reflected in cognitive participation and collective action PAP work needs to be organized at different levels for systematic monitoring/evaluation Rural perspective as a complicating factor Divergent views of benefits Low/uneven PAP prescription rates between groups Shared understanding and legitimacy (coherence) The theme " Need for legitimacy-building training activities that create consensus " covers the coherence domain of the NPT and encompasses patient expectations, awareness and a lack of consensus on PAPs. The participants described inconsistent views about PAPs’ relevance and effectiveness. Some perceived PAPs as overlapping with routine PA advice and counselling and questioned the added value, seeing PAPs as redundant with routine advice. Doubts about patient receptivity were common: "... they [patients] want the doctor's note for sick leave and are not prepared to do much... They’ve already decided beforehand. Some patients almost want to bring, yeah, they bring like their own text to the doctor, asking them to write something like this.” (Manager 2). Prescribing PAPs was also argued to be potentially uncomfortable for the prescriber, since patients could end up feeling insulted: " If it is a smoker or overweight, and then some fitness fanatic says you should exercise more, of course some might find it a bit of an invasion of privacy " (Healthcare personnel 6). Managers also described low awareness of PAPs within their teams. Manager 5 argued that “…there are probably many who barely even know what it is... ", whereas another expressed a need for PAPs to be more prominently emphasized within the workplace: " In my workplace, I think we talk too little about PAPs. In addition, overall, we probably know too little about it… we would need, above all, to highlight it in a clearer way, that’s how I feel self-critically. " (Manager 2). Meeting educational needs was considered a potential solution. Manager 4 argued that " … it’s about educational initiatives... " while another described how a course in PAP had contributed to increased motivation among participants who "... have been quite motivated, those who have participated in it now." (Manager 5). The educational need was also argued to extend to the patients themselves, who needed to be better informed of the existence of PAPs: " However, in a way, I think it’s a lack of knowledge among citizens, our patients. It might be them who need to be informed that it exists and that it could be good for them... " (Manager 1). Several respondents emphasized the need for legitimacy-building activities, such as structured training sessions, to create a shared understanding of PAPs’ purpose. The respondents specifically expressed a lack of consensus about PAPs’ added value and use, seeing PAPs as redundant with routine advice. Healthcare personnel 1 said, " That piece of paper is not so important for us in our clinical everyday work. More importantly, we have informed the patient who this is something you need to start doing. " Engagement through routines and clarity (cognitive participation) The theme “ Need for adapted materials and routines to foster engagement and participation ” covers the cognitive participation domain of the NPT, encompasses perceptions of PAPs as discontinued projects, and calls for adapted routines and clear guidelines. The respondents described PAPs as methods that had lost momentum over time, with several referring to PAPs as “forgotten projects.” Despite initial efforts to introduce PAPs, the lack of continued emphasis or integration into care processes meant that PAPs were often sidelined. This was especially common among managers, which was argued to have led to an overall loss of focus on PAPs. One manager described that: " I think there was a red thread in the introduction of it, maybe eight years ago... Eh, but somewhere along the way... then the momentum was lost and the management in it, just like with so many projects in this region... It’s a bit like ‘well, that just sort of fell through the cracks, that didn’t truly become anything’… " (Manager 5). Conversely, the absence of discussion about PAPs in some units was initially interpreted by managers as evidence of successful integration. " Well, you know, since I came here those (X) years ago, I’ve never heard of PAPs being discussed. Eh, then I thought maybe it is because it’s a well-established method... so that is why it’s not talked about in the same way. However, I realized later when the survey came, and I started asking around, that for us, it is only the physiotherapists who prescribe it. " (Manager 1). The lack of explicit guidelines and structured follow-up further hindered engagement. The participants noted that although physical activity was sometimes mentioned in care programs, PAP specifically was not mentioned, leading to vague and inconsistent use. "It’s not that it’s stated that it’s included with various diseases and so on, in the care programmes. PA is mentioned, but not specifically PAP, and then it just becomes this little... bit of advice... It’s not truly followed up ." (Manager 5). Without integration into existing workflows and follow-up structures, PAPs remained the responsibility of enthusiastic individuals rather than part of standard care. Several interviewees called for clearer procedures and embedded routines to foster sustained engagement: " If it’s going to succeed, I think it should be a central routine that ‘yes, this is how we do it’..." (Healthcare personnel 4). Leadership and structural support (collective action) The theme “ Need for clear leadership and resources for collectively sustainable PAP work ” covers the collective action domain of the NPT and encompasses an identified need for leadership and support, perceptions of motivation-building work, and technical solutions to and systematization of PAP work. Leadership and organizational support emerged as central to successful implementation. Many participants reported that PAPs were not actively promoted by managers, leaving them to individual staff to seek out information or take initiative. One respondent explained that " PAP is not something the managers have encouraged or that you actively work with on the clinic in that way, but it’s been something I’ve known about and asked around about myself ." (Healthcare personnel 9). Others emphasized the importance of role models, peer networks and accessible online resources for embedding PAPs and sustaining future efforts across geographically dispersed healthcare settings. " If the region could provide something... great examples from others. It should be simple. Not time-consuming. Because if it becomes time-consuming, it gets set aside, that is how it is." (Manager 2). The need for easy access to information was a recurring view. Manager 3 said, "... if it is easy to get the information, then if you think, ‘well, this person might need a prescription, but I’m a little unsure, it’s a while since I did it,’ then you want it to be easy to find quickly. In addition, I don’t think the region’s website is very well known for being able to quickly find what you need ." Support could also be the right people in the right place. Manager 2 said, "I could ask for help from one of my doctors, very sporty, and have her help as a kind of ambassador and maybe as a support coordinator." Similarly, technical solutions such as a simplified documentation system or a PAP app for patients were proposed to reduce administrative burden. “ I can picture an app where the patient reports their physical activity... I think it would be a bit like self-monitoring blood pressure. You might get a list of those who are in the red or orange for that week, from those you have prescribed to, and then you can quickly, like, send a little chat or.. ." (Manager 5). A clear consensus was also that PAP work needs to be systematized and formalized . For example, PAPs could be used as leverage in patient meetings if there are, e.g., financial incentives for patients, such as discounts at gyms. " I think if there were discounts, like when it was introduced, in different places, well, that might make... I think it could also motivate the personnel to prescribe more. Because they could motivate by saying... well, look, you get to try it for free, or you get a discount if you sign up for a training card there ." (Manager 3). At a structural level, the need for designated PAP coordinators within each healthcare unit, as well as at the regional level, was viewed as crucial for continuity and strategic leadership. These individuals could serve as resource persons, organize training, and facilitate collaboration across sites. Manager 5 said, " There should be someone responsible for PAPs, who has some special training and is a support for other personnel. In addition, then a network for them, so they can collaborate in the region and get ideas from each other. " Staff turnover was often cited as a barrier to the continuation of PAPs. Manager 5 explained, " Then, it is difficult for us, with so many locum doctors, who also have different experiences, and... you use it a bit differently. Therefore, there should be clearer guidelines there. " A lack of both time and resources further increased PAPs being deprioritized. " It truly is time scarcity. It feels like we’re always complaining about time, but that’s unfortunately how it is. Even though we, as physiotherapists, still have quite a bit of time for a first visit compared to doctors and nurses, it can still be difficult to manage writing out PAP, and that’s the challenge. " (Healthcare personnel 3). Additionally, managers saw time scarcity as a critical factor: "...PAP is just one of those things that gets lost when you’re busy trying to get staffing for doctors and nurses and making the day run smoothly, then it’s not a priority, for the day at least... " (Manager 5). Personnel also emphasized the difficulty of prioritizing PAPs amid competing demands. Healthcare personnel 5 said: " Yeah, I’d need 300% or 500% working time to be able to implement everything that’s cost-effective... We still must prioritize these things. What brings the most benefit? " Monitoring and long-term integration (Reflexive Monitoring) The theme " PAP work needs to be organized at different levels for systematic monitoring/evaluation " covers the reflexive monitoring domain of the NPT. Few settings track PAP use, and without clear feedback mechanisms, it is difficult for personnel to assess the effectiveness or feel ownership of the process. Barriers to reflexive monitoring were closely linked to earlier themes—limited awareness and consensus on PAPs, a varied view of the utility of PAPs, unclear routines, and insufficient systematization/formalization of PAPs—making it difficult for healthcare personnel to assess whether their efforts were effective or warranted. However, the participants offered suggestions on how to redefine procedures or modify practices to make them more workable in practice. Coordinated training for healthcare personnel, prioritization of PAPs in internal policies, and clearer integration into care workflows were all seen as potential strategies to embed monitoring more effectively. Healthcare personnel 1 framed the educational need as follows: " We’ve studied during a time when this was launched. When older employees studied, they did not discuss it in the same way. Therefore, it is a newer concept that’s come up recently, and younger people tend to pick it up through their education. " Patients were also seen as playing a role in normalization. Several respondents noted that broader public health communication could help generate demand “from below,” shifting the dynamic from one of professional push to patient pull. One manager explained: " They don’t want that basic stuff, like moving, eating healthily, sleeping… It’s more like, when you go to the doctor, you want something real, like a proper solution (…) When it spreads, and the citizens demand it themselves, it creates a different momentum… Rather than sitting there and trying… Yeah, well, have you heard about this? " (Manager 1). Most respondents argued that PAPs need to be better prioritized but also that there is a need for broader structural integration of PAPs—into public health initiatives, regional health plans, and incentive frameworks such as the “health choice” (hälsovalet) —for long-term sustainability. Manager 2 stated: " If this is something that should be prioritized, it’s also important what’s communicated to regional management above the local manager. Things that aren’t included in health choices tend to be less prioritized currently ." Discussion This study aimed to identify challenges and propose strategies and measures to strengthen the implementation of the PAP method from the perspectives of both healthcare personnel and managers. The findings reveal considerable gaps between policy intentions and everyday practices. While the quantitative data illuminated patterns of usage, attitudes, and organizational prerequisites, the qualitative findings provided depth and context, offering an understanding of the mechanisms that influence whether and how PAPs become part of routine care. While most healthcare personnel regularly provide basic advice on PAs, only 13 percent prescribe PAPs monthly, and documentation is rare. Compared with the other groups, physiotherapists were more likely to prescribe PAP and had higher self-reported competence in the method. Major barriers included time constraints, unclear procedures, limited training, inconsistent leadership, a lack of collaboration, a lack of consensus over the evidence base and usefulness of PAPs, and a lack of prioritization. Despite these challenges, there was strong interest among both personnel and managers in expanding PA counselling efforts. These findings align with previous research [ 11 , 18 – 20 ]. Despite national endorsement, PAPs are not yet fully integrated into Swedish routine healthcare [ 11 ], and in the current study, most healthcare personnel and managers expressed a desire for better conditions to work with this method. The qualitative findings confirmed that PAPs lack formal anchoring within healthcare settings. Many respondents perceived PAPs as tools that lacked added value, and some even questioned their appropriateness in certain patient interactions, fearing that they might feel intrusive or judgmental. This lack of consensus on the role and utility of PAPs undermines their legitimacy and signals a need for coordinated, legitimacy-building activities. Both healthcare personnel and managers requested improved regional and cross-sectoral collaboration with PAPs. Gustavsson et al. [ 8 ] also stressed the importance of both a regional coordination function and local key players at the clinic level to support PAP efforts. Staff turnover was also cited as a persistent barrier related to the need to retrain new staff while dealing with staff shortages. Similarly, time constraints were considered critical barriers by both managers and healthcare personnel, and many respondents indicated that PAPs were simply deprioritized in the face of other, more immediate demands. This is consistent with earlier studies highlighting that competing demands on staff time and operational pressures are significant challenges to the sustainability of health promotion interventions in clinical practice [ 33 , 34 ]. Interestingly, older healthcare personnel more often reported time constraints for PAP work, possibly reflecting differences in educational exposure to the method. However, Brorsson Lundqvist et al. [ 18 ] reported that more experienced physicians (> 10 years) were more likely to prescribe PAP than their less experienced colleagues were. Addressing staff turnover and time constraints through adequate managerial support, clear routines and ensuring time and resources to train staff as needed, not only at the beginning of implementation, could help integrate PAPs into daily practice. Another frequently cited barrier was the perceived unclear purpose of PAPs and perceptions of patients not being receptive to PAPs, particularly among managers. Healthcare personnel, meanwhile, highlighted internal barriers such as a lack of procedures and managerial support, as well as low competence. Few personnel were even aware of which colleagues were working with PAPs in their setting. These differing perceptions underscore the need for structured dialogue between management and personnel to align strategies and expectations. Despite these challenges, the study identified several opportunities to strengthen PAP efforts. Most healthcare personnel showed confidence in PAPs’ benefits and expressed a willingness to expand PA counselling. Access to simplified routines, ready-to-use patient materials (including in plain language and multiple languages), and improved collaboration with community activity providers were suggested as pragmatic next steps. Our findings also highlight the need for greater integration of PAPs into public health strategies and for regional-level initiatives to foster collaboration with external providers, such as municipalities and community activity providers. This is particularly important in rural areas, where access to activities may be limited, making such collaborations even more crucial. The inclusion of PAP indicators in internal performance goals could further strengthen its role in routine care. Finally, variations in perceptions of PAPs’ evidence base suggest a need for targeted training. While some personnel were sceptical about the method’s long-term effectiveness, others expressed disbelief in its usefulness compared with other forms of PA counselling. Although evidence supports PAPs’ ability to increase self-reported PA levels [ 16 , 35 ], uncertainties remain, especially regarding sustained behavioural change [ 36 ]. Training efforts should therefore present a balanced view, acknowledging both the strengths and limitations of the method. Strengths and Limitations A key strength of this study is its use of a mixed-methods sequential design, which combines quantitative data with interviews to generate a rich understanding of PAP implementation [ 26 ]. Collaboration with regional stakeholders enhanced the study’s contextual relevance. However, the relatively small sample size may limit rigorous statistical analysis and hence generalizability. Additionally, the risk of participation bias cannot be ruled out: those interested in PAPs may have been more inclined to participate, whereas others with negative perceptions may also have been motivated to voice concerns. Nevertheless, the presence of both perspectives in our findings helps mitigate systematic bias and build realistic insights. Future studies should consider including patient perspectives and conducting longitudinal assessments of implementation progress. Implications This study underscores the importance of aligning priorities between healthcare personnel and management to strengthen PAP implementation. Embedding PAPs in routine practice requires leadership support, adequate training, and a shared understanding of their goals and benefits. Furthermore, fostering collaboration with community-based actors is crucial, especially in rural settings where healthcare resources are more limited. Technical tools and infrastructure must support—not hinder—the work of staff. Finally, evaluation mechanisms must be implemented so that PAP practices can evolve on the basis of feedback and real-world effectiveness. Efforts to implement PAPs will likely remain fragmented unless they are integrated into broader systems of accountability and public health promotion. Aligning PAPs with local care plans, incentive systems, and regional goals may provide the structural support needed for long-term success. These insights can inform strategies to integrate PAPs more effectively, both in Sweden and in other countries seeking to address physical inactivity and promote health equity. Conclusions In this study, PAPs were widely regarded as evidence-based and relevant by both healthcare personnel and managers, yet their use was inconsistent and poorly integrated into routine practice. The key barriers included (i) time constraints, (ii) a lack of shared understanding, (iii) weak engagement, (iv) insufficient leadership, and (v) minimal systematic follow-up. These challenges highlight that simply introducing an evidence-based method is not enough; success depends on shared understanding, clear roles, and active support within the healthcare system. Despite these challenges, healthcare personnel expressed a desire to increase their involvement in PAP counselling, and managers wanted personnel to take a more active role. This shared commitment offers a promising foundation. However, divergent views on responsibilities and barriers underscore the need for improved communication and unified strategies. To address these issues, our study suggests clear prioritization by healthcare management, continuous training, and supportive organizational structures. Access to simplified patient materials, collaboration with community-based activity providers, and the appointment of local PAP coordinators were also identified as important steps. These measures should be embedded in a long-term public health strategy that is not treated as temporary initiatives. Abbreviations FYSS: Physical activity in the prevention and treatment of disease (Fysisk aktivitet i sjukdomsprevention och sjukdomsbehandling) NPT: normalization process theory PA: Physical activity PAP: Physical activity on prescription KVÅ Declarations Ethics approval and consent to participate A formal ethical application was not submitted to the Swedish Ethical Review Authority, as the study qualifies as a quality development project conducted in accordance with the Health and Medical Services Act (1982:763), which does not require ethical review under the Swedish Ethical Review Act (2003:460). Furthermore, the study was entirely based on de-identified data, which also exempts it from mandatory ethical review. However, a formal ethical application was submitted to and reviewed by the Research Ethics Advisory Board at Mid Sweden University, which raised no objections (Dnr:2023/3163). Individual participants provided written informed consent to participate. This study adhered to the ethical principles outlined in the Declaration of Helsinki. Consent for publication Not applicable. Availability of data and materials The datasets generated and/or analysed during the current study are available from the corresponding authors upon reasonable request. Competing interests The authors declare that they have no competing interests. Funding This study received no external funding. Authors' contributions MM was the principal investigator (PI) and conceived the design of the study together with DS, AM, AH and TA. All the authors participated in the quantitative data collection. The interviews were conducted by DS, AM, AH and TA. MM, AH, AM and TA conducted the quantitative analysis, and DS conducted the qualitative analysis with assistance from MM. DS and MM drafted the manuscript, with contributions from AH, AM and TA. All the authors read and approved the final manuscript. Acknowledgements We would like to thank the health care personnel and managers who gave their time and shared their views with us. We would also like to thank Cecilia Andersson, the regional PAP coordinator, and Johan Börjesson, the director of the regional public health department. References World Health Organization. Global status report on physical activity 2022. Geneva: WHO; 2022. Available from: https://tinyurl.com/bde5k6t2 Costa Santos A, Willumsen J, Meheus F, Ilbaw A, Bull FC. The cost of inaction on physical activity to healthcare systems. Lancet Glob Health. 2023;11(1):32–9. Public Health Agency of Sweden (Folkhälsomyndigheten). Rekommendationer för fysisk aktivitet och stillasittande. 2023. 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Exercise/physical activity and health outcomes: an overview of Cochrane systematic reviews. BMC Public Health. 2020;20:1724. Additional Declarations No competing interests reported. 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Design","fulltext":[{"header":"Background","content":"\u003cp\u003ePhysical inactivity is a major contributor to the global burden of noncommunicable diseases (NCDs) and premature mortality [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The World Health Organization (WHO) attributed 20\u0026ndash;30% of premature deaths to insufficient physical activity (PA) and estimated that 500\u0026nbsp;million preventable NCD cases may have occurred between 2020 and 2030 due to inactivity [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], with an associated annual healthcare cost of up to 27\u0026nbsp;billion US dollars [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Despite the WHO recommendations of 150\u0026ndash;300 minutes of moderate PA per week [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], over 25% of adults globally\u0026mdash;and 34% in Sweden\u0026mdash;fail to meet this target [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePromoting PA is a core goal in both global and national health strategies and is a key component of Goal 3 of the UN\u0026rsquo;s Agenda 2030, which aims to ensure healthy lives and promote well-being for all ages [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In Sweden, PA is embedded in national public health goals related to lifestyle behaviours and health equity [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The Commission for Equity in Health [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] emphasized the need to strengthen individuals\u0026rsquo; ability to promote health and prevent illness. The healthcare sector plays a central role in this effort, given its wide population reach and high credibility as a source of health information [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. In 2021 alone, Swedish primary care records more than 36\u0026nbsp;million visits [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], highlighting its significant potential as an arena for preventive interventions.\u003c/p\u003e \u003cp\u003eThe National Board of Health and Welfare (NBHW) in Sweden recommends the use of physical activity on prescription (PAP) for patients at risk owing to low levels of PA [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The PAP model involves tailoring prescriptions to an individual\u0026rsquo;s health status, motivation, self-efficacy, and goals, with decisions guided by the severity of the condition and expected outcomes [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. In 2001, PAP included individualized counselling, a written prescription, follow-up, and clinical guidance on the basis of the FYSS (Physical Activity in the Prevention and Treatment of Disease) handbook [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Collaboration with community-based activity providers is also encouraged. PAPs are currently implemented in all Swedish regions and are being adopted in other European countries [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEvidence indicates that PAP can increase PA levels, improve quality of life [\u003cspan additionalcitationids=\"CR13 CR14\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], and offer long-term health and economic benefits [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. However, prescription rates remain inconsistent across regions [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], and PAPs are often viewed more as a secondary measure than as part of standard care and a routine practice [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSeveral barriers hinder effective implementation, including unfamiliarity with PAPs, limited knowledge of their evidence base and preventive role, lack of managerial support, insufficient training, unclear routines, and time constraints [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Differences in regional support structures, training opportunities, and professional networks contribute to unequal delivery across the country [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAs with other complex interventions, the implementation of PAPs is highly context dependent. Conditions that promote success in one setting may be ineffective\u0026mdash;or even counterproductive\u0026mdash;in another [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Context encompasses both structural factors (e.g., staffing levels, geographic location) and social dynamics (e.g., routines, leadership, interprofessional relationships) [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Implementation processes can, in turn, reshape these dynamics [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], and sustained success depends on behaviour change at both the individual and organisational levels [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eNormalization process theory (NPT) provides a valuable framework for studying the implementation of complex interventions [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. It focuses on how new practices become embedded in everyday clinical work [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] through four interrelated constructs: (i) coherence\u0026mdash;how participants understand and make sense of the intervention, including its relevance and purpose; (ii) cognitive participation\u0026mdash;the level of engagement and commitment among actors to adopt and sustain the practice; (iii) collective action\u0026mdash;the operational work required to implement the practice, including task distribution and collaboration; and (iv) reflexive monitoring\u0026mdash;the process through which individuals and teams assess effectiveness and adapt practices over time [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough PAPs are formally adopted by all 21 Swedish regions, decentralization has resulted in uneven implementation [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. A sparsely populated region, located in mid-Sweden, has among the country\u0026rsquo;s lowest rates of PAP prescriptions [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Gaining a deeper understanding of barriers and facilitators in such underperforming contexts can inform more targeted and effective implementation strategies, both regionally and nationally.\u003c/p\u003e \u003cp\u003eThis study aimed to identify barriers and potential mitigation strategies to strengthen PAP implementation, as perceived by healthcare personnel and managers in a rural region where primary healthcare services are geographically dispersed.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis was a mixed-methods study with an explanatory sequential design [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] in a sparsely populated region in mid-Sweden during spring 2024. The quantitative survey data informed the subsequent qualitative interviews [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. The study was carried out in collaboration between Mid Sweden University and the regional public health department, and the reporting adhered to the STROBE [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] and COREQ [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] guidelines.\u003c/p\u003e \u003cp\u003eThe study setting was Sweden\u0026rsquo;s third largest region by area, a sparsely populated region (~\u0026thinsp;130,000 residents), with a mix of rural and urban communities [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Approximately one-third of the population lives in rural areas [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Healthcare services in this rural region are geographically dispersed, with limited staff and resources, and the long distances involved add further complexity to implementation efforts.\u003c/p\u003e \u003cp\u003eLicenced healthcare personnel authorized to prescribe PAPs (e.g., physicians, nurses, physiotherapists) in primary healthcare settings, including a habilitation clinic and a day psychiatry clinic, and their managers participated. Surveys were distributed via internal channels and reached approximately 140 out of approximately 350 eligible personnel and 20 managers out of 36. Reminder emails and calls were used to increase response rates. At survey completion, participants could volunteer for interviews. Interview informants were recruited through digital questionnaires, where participants could provide their contact details if they consented to take part in individual interviews. This process yielded 14 informants (9 personnel members and 5 managers), representing a range of roles and settings. All participants in the questionnaire surveys received written information about the study and its aim. Consent was obtained through completion of the questionnaire. Those who agreed to participate in interviews received both written and verbal information and provided informed consent.\u003c/p\u003e \u003cp\u003eTwo structured online surveys were developed via Qualtrics software [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e], a digital survey tool, one for healthcare personnel (36 items) and one for managers (16 items). The items included Likert scales, multiple-choice questions, and optional free-text responses. The surveys were refined through feedback from pilot testers (n\u0026thinsp;=\u0026thinsp;13) and regional stakeholders. Of those reached, 75 personnel and 18 managers completed the surveys, yielding response rates of 54 percent and 90 percent, respectively.\u003c/p\u003e \u003cp\u003eSemistructured interviews were conducted with 14 volunteers via Microsoft Teams, which lasted between 32 and 43 minutes, with one exception in which the respondent was interrupted by work, resulting in a shorter duration of 21 minutes. The interviews were recorded, transcribed verbatim, and guided by the four domains of the NPT [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Five interviewees also reviewed a summary of the preliminary survey results.\u003c/p\u003e \u003cp\u003eThe quantitative data were analysed via SPSS (v29) via descriptive statistics, such as Pearson\u0026rsquo;s chi-square test, Fisher\u0026rsquo;s exact test, and binary logistic regression with odds ratios (ORs) and confidence intervals (CIs). A significance level of p\u0026thinsp;\u0026lt;\u0026thinsp;.05 was applied throughout. Qualitative data, including interview transcripts and open-ended survey responses, were analysed deductively via content analysis [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. The analysis began with an initial reading of the transcripts to familiarize them with the data, after which meaning units were identified and coded according to the NPT constructs [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Coding was performed by DS and then secondarily by MM. Discussions with the AM, AH, and TA were held to enhance credibility and ensure intercoder consistency, and discrepancies were resolved through further discussion.\u003c/p\u003e \u003cp\u003eThe interdisciplinary research team included members with backgrounds in public health, medicine, nursing, habilitation, and geography. All the participants shared an interpretivist orientation and viewed healthcare as a complex adaptive system (CAS), recognizing that implementation efforts are influenced by dynamic interactions between system actors and contextual factors [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Reflexive notes were kept throughout to support transparency.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe survey was completed by 93 participants, comprising 75 healthcare personnel and 18 managers, where a majority were women (75%), representing diverse professional backgrounds (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\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\u003eSurvey respondent characteristics.\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\u003eGender\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e75.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNonbinary/do not wish to disclose\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (1/2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge (healthcare personnel only)\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 \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e20\u0026ndash;35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e36\u0026ndash;45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e46\u0026ndash;55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e55+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eProfession\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 \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhysiotherapist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDoctor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16,1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOccupational therapist\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\u003e5.4\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\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4,3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eManager\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eYears in Current Profession (healthcare personnel only)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u0026ndash;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u0026ndash;20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e21+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eUnit (healthcare personnel only)\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 \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRegional health centre\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e54.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrivate health centre\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePsychiatry\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHabilitation (adult/child)\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\u003e8.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eUnit (managers)\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 \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRegional health centre\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e77.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePsychiatry and habilitation\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\u003e22.2\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\u003eWhile 77% of personnel reported providing basic PA advice regularly, only 13% prescribed PAPs monthly or more. Documentation of PAPs in medical records via Classification of Health Care Interventions Codes [KV\u0026Aring;] was rare (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\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\u003eHealthcare Personnel\u0026rsquo;s SelfReported Use of PAP Components.\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\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eHow often do you provide basic advice on PA? (n\u0026thinsp;=\u0026thinsp;75)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDaily\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e46.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOnce or a few times per week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA few times per month\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA few times per year or never\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHow often do you provide counselling about PA? (n\u0026thinsp;=\u0026thinsp;72)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDaily\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15,1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOnce or a few times per week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24,7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA few times per month\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22,6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA few times per year or never\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15,1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHow often do you prescribe PAP? (n\u0026thinsp;=\u0026thinsp;72)\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 \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDaily\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\u003e1,1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOnce or a few times per week\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\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA few times per month\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\u003e11,8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA few times per year or never\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e64,5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAre patients who receive a PAP prescription followed up? (n\u0026thinsp;=\u0026thinsp;75)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes, usually\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26,9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRarely, or never\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\u003e10,8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI do not prescribe PAP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43,0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDocumentation in the medical record - Basic advice (n\u0026thinsp;=\u0026thinsp;74)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlways/often\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4/9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5,4/12,1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRarely/never\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16/45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21,6/60,8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDocumentation in the medical record \u0026ndash; Counselling (n\u0026thinsp;=\u0026thinsp;74)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlways/often\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2/7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2,7/9,4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRarely/never\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15/50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20.2/67.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDocumentation in the medical record [KV\u0026Aring;*] - Qualified counselling (n\u0026thinsp;=\u0026thinsp;74)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlways/often\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3/7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.0/9.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRarely/never\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18/46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24.3/62.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDocumentation in the medical record [KV\u0026Aring;*] - PAP (n\u0026thinsp;=\u0026thinsp;74)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlways/often\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9/5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.1/6,7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRarely/never\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10/50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.5/67.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDocumentation in the medical record [KV\u0026Aring;*] \u0026ndash; Follow up on PAP (n\u0026thinsp;=\u0026thinsp;74)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlways/often\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7/6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9,4/8,1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRarely/never\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9/52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.1/70.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003e* Classification of Health Care Intervention Codes [KVÅ]\u003c/h3\u003e\n\u003cp\u003eBivariate analysis revealed associations between age and PAP prescription. Older personnel (36+) were more likely to provide basic advice than younger personnel (20\u0026ndash;35 years), whereas younger personnel were more likely to prescribe PAPs (Additional file 1). However, physiotherapists were more likely to prescribe PAP than other professionals were adjusted for age (OR 4.0, CI 1.01\u0026ndash;15.83) (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\u003eBinary logistic regression of PAP prescription by age and profession (n\u0026thinsp;=\u0026thinsp;72).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\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 \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndependent variables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSig.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\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 \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eLower\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eUpper\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge: 20\u0026ndash;35\u003c/p\u003e \u003cp\u003eRef: 36+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.111\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.763\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e13.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhysiotherapists\u003cb\u003e*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1,.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.048\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e15.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e*Ref: Other professions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003ePerceived Competence in PAPs\u003c/h3\u003e\n\u003cp\u003eSelf-reported competence in prescribing PAPs varies among healthcare personnel. While the vast majority of the participants felt confident in providing basic advice or counselling, 50% rated their competence in prescribing PAPs as low or very low (Additional file 2). Compared with other professionals, physiotherapists reported higher levels of competence in components of PAP, such as PA counselling and follow-up, and they also more frequently documented using classification codes of health care measures (Additional file 3).\u003c/p\u003e \u003cp\u003eFew personnel had received PAP training (38%, n\u0026thinsp;=\u0026thinsp;28), and 69% (n\u0026thinsp;=\u0026thinsp;52) were unaware that training had previously been offered. A majority of the personnel lacked access to guidance or support materials in their daily work, and 81% (n\u0026thinsp;=\u0026thinsp;61) were unaware of the national short version of the PAP guidelines for clinics.\u003c/p\u003e\n\u003ch3\u003ePerceived Barriers\u003c/h3\u003e\n\u003cp\u003ePAP work consists of multiple components and is accompanied by various challenges, as demonstrated by the barriers identified in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. Time constraints and a lack of guidelines were the two main barriers in both groups. Among the personnel, this was followed by a lack of knowledge among personnel and management, whereas the manger reported the unclear purpose of PAPs and that patients do not want to have PAPs.\u003c/p\u003e \u003cp\u003eWhile perceived time constraints were commonly reported, a binary logistic regression indicated that personnel aged\u0026thinsp;\u0026ge;\u0026thinsp;46 years, compared with those aged\u0026thinsp;\u0026le;\u0026thinsp;45 years, were more likely to perceive time constraints as barriers to PAP (OR 3.6, CI 1.27\u0026ndash;10.16) when adjusted for gender and profession.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eHealthcare Personnel\u0026rsquo;s Perceived Barriers and Suggested Implementation Measures for PAP Adoption\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\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 \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003ePerceived barriers and mitigating strategies\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTotal (N\u0026thinsp;=\u0026thinsp;93)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHealthcare\u003c/p\u003e \u003cp\u003epersonnel (n\u0026thinsp;=\u0026thinsp;75)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eManagers (n\u0026thinsp;=\u0026thinsp;18)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eFisher\u0026rsquo;s exact test\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBarriers\u003c/b\u003e:\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerceived time constraints\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e49 (52.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41 (54.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (44.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLack of guidelines on PAP procedures et cetera within the region\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45 (48.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38 (50.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (38.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e.437\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLack of knowledge among healthcare personnel\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40 (43.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37 (49.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (16.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e.\u003cb\u003e016\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLack of knowledge/interest from management\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36 (38.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34 (45.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (11.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e\u003cb\u003e.007\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnclear purpose of PAP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24 (25.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (22.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (38.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e.228\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient not receptive to/do not want PAP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21 (22.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (20.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e.227\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLack of financial incentives\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (15.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (16.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (11.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e1.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTechnical barriers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (7.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (9.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e.339\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI have no opinion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (9.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (9.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (11.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e1.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePotential mitigating strategies\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducate more healthcare personnel in the PAP method\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e54 (58.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48 (64.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e\u003cb\u003e.031\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIncrease knowledge about PA/PAP among the population\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41 (44.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32 (42.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9 (50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e.606\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eManagement needs to prioritize PAP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35 (37.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32 (42.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (16.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e\u003cb\u003e.041\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImprove access to information about PAP for personnel (e.g. on the region's website)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35 (37.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29 (38.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e.790\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIncreased collaboration on PAP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27 (29.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22 (29.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (27.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e1.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSimplify the systems (such as documentation)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 (26.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22 (29.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (16.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e.380\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePossibility to delegate follow-up of PAP to someone other than prescriber\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22 (23.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 (26.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e.224\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFinancial incentives for PAP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22 (23.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (21.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e.355\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI have no opinion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (8.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (5.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (22.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e.043\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003ePotential Mitigating Strategies\u003c/h3\u003e\n\u003cp\u003eThe most frequently suggested mitigating measure to improve PAP work was to educate more healthcare personnel on this method (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). It was proposed by 64% of personnel but only 33% of managers. Personnel were also more likely than managers to cite the need for management to prioritize PAPs (43% vs. 17%). Approximately half of both personnel and managers highlighted the need to raise public awareness of PAPs. Additionally, approximately one-third of both groups emphasized the need to improve personnel access to information about PAPs and to enhance collaboration in their implementation (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAn additional finding was that over half of healthcare personnel (52%, n\u0026thinsp;=\u0026thinsp;39) expressed a need for improved patient materials in plain Swedish for groups requiring them, and 59% (n\u0026thinsp;=\u0026thinsp;44) also wanted materials available in other languages. A large majority (80%, n\u0026thinsp;=\u0026thinsp;60) highlighted the need for collaboration with community activity providers, such as gyms and sports clubs, whereas 84% (n\u0026thinsp;=\u0026thinsp;63) believed that a consolidated list of home-based activity suggestions would support PAP work.\u003c/p\u003e \u003cp\u003eOver half of the respondents reported confidence in the method\u0026rsquo;s potential, both as an effective treatment method and to promote health (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). However, about a third stated they had no opinion, and a small share argued that evidence was poor or very poor.\u003c/p\u003e \u003cp\u003eCompared with male personnel (n\u0026thinsp;=\u0026thinsp;8/14, 57%), female personnel were more likely (n\u0026thinsp;=\u0026thinsp;36/41, 88%) to express trust in evidence for PAP as an effective treatment method or as part of treatment for certain diseases (p\u0026thinsp;=\u0026thinsp;.013).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePerceptions of Research Evidence for PAPs as a Trust Method.\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\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eEvidence for PAP as an effective method to promote health (healthcare personnel and managers, n\u0026thinsp;=\u0026thinsp;93)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVery strong evidence/Strong evidence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9/41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e9.7/44.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVery poor evidence/Poor evidence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10/3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e10.8/3.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo opinion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e30.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEvidence for PAP as an effective treatment method/part of treatment (healthcare personnel and managers. n\u0026thinsp;=\u0026thinsp;93)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVery strong evidence/Strong evidence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7/39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e7.7/42.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVery poor evidence/Poor evidence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8/3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e8.8/3.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo opinion.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e37.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eDespite the identified barriers and the low number of PAP prescriptions 69% (n\u0026thinsp;=\u0026thinsp;50) of healthcare personnel expressed a desire to increase their involvement in physical activity counselling. Similarly, 75% (n\u0026thinsp;=\u0026thinsp;12) of managers wanted their staff to work more with PA counselling.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c4\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eQualitative findings\u003c/h2\u003e \u003cp\u003eThe qualitative analysis began by categorizing the open-ended responses from the survey into the NPT domains. An example of how the responses were sorted is shown in Additional file 4. The overall findings from the qualitative analysis revealed four themes (Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eQualitative Themes Illustrating Barriers to PAP Work and Corresponding Implementation Solutions (healthcare personnel\u0026thinsp;=\u0026thinsp;9; managers\u0026thinsp;=\u0026thinsp;5).\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 \u003cp\u003eDomain of NPT\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCode\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTheme\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eCoherence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eStrong/poor evidence for PAP\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eLack of consensus regarding PAP as a method\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eNeed for legitimacy-building training activities that create consensus\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eMeeting patient expectations\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eLack of anchoring in scope of practice/Statutory role description\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eLack of formal responsibility\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eResponsibility\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003eCognitive participation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003ePraxis norms vary\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eGeneralization and short-sightedness\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e\u003cb\u003eNeed for adapted materials and routines to foster engagement and participation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eNeed for adapted routines and guidelines\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eProjects hinder long-term implementation\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eHealth information/education\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e\u0026ldquo;It takes two to tango\u0026rdquo; in patient encounter\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eSense of competence\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"6\" rowspan=\"7\"\u003e \u003cp\u003eCollective action\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eSystematization and formalization\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eStructural organization\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"6\" rowspan=\"7\"\u003e \u003cp\u003e\u003cb\u003eNeed for clear leadership and resources for a collectively sustainable PAP work\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eCross-sector collaboration\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eFinancial incentives\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e\u003cb\u003eFinding the right tools and support\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eMotivation-building\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eOvercome time- and resource shortages\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eSupport resources\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eTechnical solutions\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eReflexive monitoring/evaluation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eHeterogeneous group working across various healthcare settings\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eUnsynchronized PAP work reflected in cognitive participation and collective action\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003ePAP work needs to be organized at different levels for systematic monitoring/evaluation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eRural perspective as a complicating factor\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eDivergent views of benefits\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eLow/uneven PAP prescription rates between groups\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eShared understanding and legitimacy (coherence)\u003c/h3\u003e\n\u003cp\u003eThe theme \"\u003cem\u003eNeed for legitimacy-building training activities that create consensus\u003c/em\u003e\" covers the coherence domain of the NPT and encompasses patient expectations, awareness and a lack of consensus on PAPs.\u003c/p\u003e \u003cp\u003eThe participants described inconsistent views about PAPs\u0026rsquo; relevance and effectiveness. Some perceived PAPs as overlapping with routine PA advice and counselling and questioned the added value, seeing PAPs as redundant with routine advice. Doubts about patient receptivity were common:\u003c/p\u003e \u003cp\u003e\"...\u003cem\u003ethey [patients] want the doctor's note for sick leave and are not prepared to do much... They\u0026rsquo;ve already decided beforehand. Some patients almost want to bring, yeah, they bring like their own text to the doctor, asking them to write something like this.\u0026rdquo;\u003c/em\u003e (Manager 2).\u003c/p\u003e \u003cp\u003ePrescribing PAPs was also argued to be potentially uncomfortable for the prescriber, since patients could end up feeling insulted: \"\u003cem\u003eIf it is a smoker or overweight, and then some fitness fanatic says you should exercise more, of course some might find it a bit of an invasion of privacy\u003c/em\u003e\" (Healthcare personnel 6).\u003c/p\u003e \u003cp\u003eManagers also described low awareness of PAPs within their teams. Manager 5 argued that \u003cem\u003e\u0026ldquo;\u0026hellip;there are probably many who barely even know what it is...\u003c/em\u003e\", whereas another expressed a need for PAPs to be more prominently emphasized within the workplace:\u003c/p\u003e \u003cp\u003e\"\u003cem\u003eIn my workplace, I think we talk too little about PAPs. In addition, overall, we probably know too little about it\u0026hellip; we would need, above all, to highlight it in a clearer way, that\u0026rsquo;s how I feel self-critically.\u003c/em\u003e\" (Manager 2).\u003c/p\u003e \u003cp\u003eMeeting educational needs was considered a potential solution. Manager 4 argued that \"\u003cem\u003e\u0026hellip; it\u0026rsquo;s about educational initiatives...\u003c/em\u003e\" while another described how a course in PAP had contributed to increased motivation among participants who \"...\u003cem\u003ehave been quite motivated, those who have participated in it now.\"\u003c/em\u003e (Manager 5).\u003c/p\u003e \u003cp\u003eThe educational need was also argued to extend to the patients themselves, who needed to be better informed of the existence of PAPs:\u003c/p\u003e \u003cp\u003e\"\u003cem\u003eHowever, in a way, I think it\u0026rsquo;s a lack of knowledge among citizens, our patients. It might be them who need to be informed that it exists and that it could be good for them...\u003c/em\u003e\" (Manager 1).\u003c/p\u003e \u003cp\u003eSeveral respondents emphasized the need for legitimacy-building activities, such as structured training sessions, to create a shared understanding of PAPs\u0026rsquo; purpose. The respondents specifically expressed a lack of consensus about PAPs\u0026rsquo; added value and use, seeing PAPs as redundant with routine advice. Healthcare personnel 1 said, \"\u003cem\u003eThat piece of paper is not so important for us in our clinical everyday work. More importantly, we have informed the patient who this is something you need to start doing.\u003c/em\u003e\"\u003c/p\u003e\n\u003ch3\u003eEngagement through routines and clarity (cognitive participation)\u003c/h3\u003e\n\u003cp\u003eThe theme \u0026ldquo;\u003cem\u003eNeed for adapted materials and routines to foster engagement and participation\u003c/em\u003e\u0026rdquo; covers the cognitive participation domain of the NPT, encompasses perceptions of PAPs as discontinued projects, and calls for adapted routines and clear guidelines.\u003c/p\u003e \u003cp\u003eThe respondents described PAPs as methods that had lost momentum over time, with several referring to PAPs as \u0026ldquo;forgotten projects.\u0026rdquo; Despite initial efforts to introduce PAPs, the lack of continued emphasis or integration into care processes meant that PAPs were often sidelined. This was especially common among managers, which was argued to have led to an overall loss of focus on PAPs. One manager described that:\u003c/p\u003e \u003cp\u003e\"\u003cem\u003eI think there was a red thread in the introduction of it, maybe eight years ago... Eh, but somewhere along the way... then the momentum was lost and the management in it, just like with so many projects in this region... It\u0026rsquo;s a bit like \u0026lsquo;well, that just sort of fell through the cracks, that didn\u0026rsquo;t truly become anything\u0026rsquo;\u0026hellip;\u003c/em\u003e\" (Manager 5).\u003c/p\u003e \u003cp\u003eConversely, the absence of discussion about PAPs in some units was initially interpreted by managers as evidence of successful integration.\u003c/p\u003e \u003cp\u003e\"\u003cem\u003eWell, you know, since I came here those (X) years ago, I\u0026rsquo;ve never heard of PAPs being discussed. Eh, then I thought maybe it is because it\u0026rsquo;s a well-established method... so that is why it\u0026rsquo;s not talked about in the same way. However, I realized later when the survey came, and I started asking around, that for us, it is only the physiotherapists who prescribe it.\u003c/em\u003e\" (Manager 1).\u003c/p\u003e \u003cp\u003e The lack of explicit guidelines and structured follow-up further hindered engagement. The participants noted that although physical activity was sometimes mentioned in care programs, PAP specifically was not mentioned, leading to vague and inconsistent use.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"It\u0026rsquo;s not that it\u0026rsquo;s stated that it\u0026rsquo;s included with various diseases and so on, in the care programmes. PA is mentioned, but not specifically PAP, and then it just becomes this little... bit of advice... It\u0026rsquo;s not truly followed up\u003c/em\u003e.\" (Manager 5).\u003c/p\u003e \u003cp\u003eWithout integration into existing workflows and follow-up structures, PAPs remained the responsibility of enthusiastic individuals rather than part of standard care. Several interviewees called for clearer procedures and embedded routines to foster sustained engagement:\u003c/p\u003e \u003cp\u003e\"\u003cem\u003eIf it\u0026rsquo;s going to succeed, I think it should be a central routine that \u0026lsquo;yes, this is how we do it\u0026rsquo;...\"\u003c/em\u003e (Healthcare personnel 4).\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eLeadership and structural support (collective action)\u003c/h2\u003e \u003cp\u003eThe theme \u0026ldquo;\u003cem\u003eNeed for clear leadership and resources for collectively sustainable PAP work\u003c/em\u003e\u0026rdquo; covers the collective action domain of the NPT and encompasses an identified need for leadership and support, perceptions of motivation-building work, and technical solutions to and systematization of PAP work.\u003c/p\u003e \u003cp\u003eLeadership and organizational support emerged as central to successful implementation. Many participants reported that PAPs were not actively promoted by managers, leaving them to individual staff to seek out information or take initiative. One respondent explained that \"\u003cem\u003ePAP is not something the managers have encouraged or that you actively work with on the clinic in that way, but it\u0026rsquo;s been something I\u0026rsquo;ve known about and asked around about myself\u003c/em\u003e.\" (Healthcare personnel 9).\u003c/p\u003e \u003cp\u003eOthers emphasized the importance of role models, peer networks and accessible online resources for embedding PAPs and sustaining future efforts across geographically dispersed healthcare settings. \"\u003cem\u003eIf the region could provide something... great examples from others. It should be simple. Not time-consuming. Because if it becomes time-consuming, it gets set aside, that is how it is.\"\u003c/em\u003e (Manager 2). The need for easy access to information was a recurring view. Manager 3 said, \"... \u003cem\u003eif it is easy to get the information, then if you think, \u0026lsquo;well, this person might need a prescription, but I\u0026rsquo;m a little unsure, it\u0026rsquo;s a while since I did it,\u0026rsquo; then you want it to be easy to find quickly. In addition, I don\u0026rsquo;t think the region\u0026rsquo;s website is very well known for being able to quickly find what you need\u003c/em\u003e.\"\u003c/p\u003e \u003cp\u003eSupport could also be the right people in the right place. Manager 2 said, \u003cem\u003e\"I could ask for help from one of my doctors, very sporty, and have her help as a kind of ambassador and maybe as a support coordinator.\"\u003c/em\u003e Similarly, technical solutions such as a simplified documentation system or a PAP app for patients were proposed to reduce administrative burden.\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eI can picture an app where the patient reports their physical activity... I think it would be a bit like self-monitoring blood pressure. You might get a list of those who are in the red or orange for that week, from those you have prescribed to, and then you can quickly, like, send a little chat or..\u003c/em\u003e.\" (Manager 5).\u003c/p\u003e \u003cp\u003eA clear consensus was also that PAP work needs to be \u003cb\u003esystematized\u003c/b\u003e and \u003cb\u003eformalized\u003c/b\u003e. For example, PAPs could be used as leverage in patient meetings if there are, e.g., financial incentives for patients, such as discounts at gyms.\u003c/p\u003e \u003cp\u003e\"\u003cem\u003eI think if there were discounts, like when it was introduced, in different places, well, that might make... I think it could also motivate the personnel to prescribe more. Because they could motivate by saying... well, look, you get to try it for free, or you get a discount if you sign up for a training card there\u003c/em\u003e.\" (Manager 3).\u003c/p\u003e \u003cp\u003eAt a structural level, the need for designated PAP coordinators within each healthcare unit, as well as at the regional level, was viewed as crucial for continuity and strategic leadership. These individuals could serve as resource persons, organize training, and facilitate collaboration across sites. Manager 5 said, \"\u003cem\u003eThere should be someone responsible for PAPs, who has some special training and is a support for other personnel. In addition, then a network for them, so they can collaborate in the region and get ideas from each other.\u003c/em\u003e\"\u003c/p\u003e \u003cp\u003eStaff turnover was often cited as a barrier to the continuation of PAPs. Manager 5 explained, \"\u003cem\u003eThen, it is difficult for us, with so many locum doctors, who also have different experiences, and... you use it a bit differently. Therefore, there should be clearer guidelines there.\u003c/em\u003e\" A lack of both time and resources further increased PAPs being deprioritized. \"\u003cem\u003eIt truly is time scarcity. It feels like we\u0026rsquo;re always complaining about time, but that\u0026rsquo;s unfortunately how it is. Even though we, as physiotherapists, still have quite a bit of time for a first visit compared to doctors and nurses, it can still be difficult to manage writing out PAP, and that\u0026rsquo;s the challenge.\u003c/em\u003e\" (Healthcare personnel 3). Additionally, managers saw time scarcity as a critical factor: \u003cem\u003e\"...PAP is just one of those things that gets lost when you\u0026rsquo;re busy trying to get staffing for doctors and nurses and making the day run smoothly, then it\u0026rsquo;s not a priority, for the day at least...\u003c/em\u003e\" (Manager 5).\u003c/p\u003e \u003cp\u003ePersonnel also emphasized the difficulty of prioritizing PAPs amid competing demands. Healthcare personnel 5 said:\u003c/p\u003e \u003cp\u003e\"\u003cem\u003eYeah, I\u0026rsquo;d need 300% or 500% working time to be able to implement everything that\u0026rsquo;s cost-effective... We still must prioritize these things. What brings the most benefit?\u003c/em\u003e\"\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eMonitoring and long-term integration (Reflexive Monitoring)\u003c/h2\u003e \u003cp\u003eThe theme \"\u003cem\u003ePAP work needs to be organized at different levels for systematic monitoring/evaluation\u003c/em\u003e\" covers the reflexive monitoring domain of the NPT. Few settings track PAP use, and without clear feedback mechanisms, it is difficult for personnel to assess the effectiveness or feel ownership of the process.\u003c/p\u003e \u003cp\u003eBarriers to reflexive monitoring were closely linked to earlier themes\u0026mdash;limited awareness and consensus on PAPs, a varied view of the utility of PAPs, unclear routines, and insufficient systematization/formalization of PAPs\u0026mdash;making it difficult for healthcare personnel to assess whether their efforts were effective or warranted. However, the participants offered suggestions on how to redefine procedures or modify practices to make them more workable in practice. Coordinated training for healthcare personnel, prioritization of PAPs in internal policies, and clearer integration into care workflows were all seen as potential strategies to embed monitoring more effectively. Healthcare personnel 1 framed the educational need as follows: \"\u003cem\u003eWe\u0026rsquo;ve studied during a time when this was launched. When older employees studied, they did not discuss it in the same way. Therefore, it is a newer concept that\u0026rsquo;s come up recently, and younger people tend to pick it up through their education.\u003c/em\u003e\"\u003c/p\u003e \u003cp\u003ePatients were also seen as playing a role in normalization. Several respondents noted that broader public health communication could help generate demand \u0026ldquo;from below,\u0026rdquo; shifting the dynamic from one of professional push to patient pull. One manager explained:\u003c/p\u003e \u003cp\u003e\"\u003cem\u003eThey don\u0026rsquo;t want that basic stuff, like moving, eating healthily, sleeping\u0026hellip; It\u0026rsquo;s more like, when you go to the doctor, you want something real, like a proper solution (\u0026hellip;) When it spreads, and the citizens demand it themselves, it creates a different momentum\u0026hellip; Rather than sitting there and trying\u0026hellip; Yeah, well, have you heard about this?\u003c/em\u003e\" (Manager 1).\u003c/p\u003e \u003cp\u003eMost respondents argued that PAPs need to be better prioritized but also that there is a need for broader structural integration of PAPs\u0026mdash;into public health initiatives, regional health plans, and incentive frameworks such as the \u0026ldquo;health choice\u0026rdquo; (h\u0026auml;lsovalet) \u0026mdash;for long-term sustainability. Manager 2 stated:\u003c/p\u003e \u003cp\u003e\"\u003cem\u003eIf this is something that should be prioritized, it\u0026rsquo;s also important what\u0026rsquo;s communicated to regional management above the local manager. Things that aren\u0026rsquo;t included in health choices tend to be less prioritized currently\u003c/em\u003e.\"\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study aimed to identify challenges and propose strategies and measures to strengthen the implementation of the PAP method from the perspectives of both healthcare personnel and managers. The findings reveal considerable gaps between policy intentions and everyday practices. While the quantitative data illuminated patterns of usage, attitudes, and organizational prerequisites, the qualitative findings provided depth and context, offering an understanding of the mechanisms that influence whether and how PAPs become part of routine care.\u003c/p\u003e \u003cp\u003eWhile most healthcare personnel regularly provide basic advice on PAs, only 13 percent prescribe PAPs monthly, and documentation is rare. Compared with the other groups, physiotherapists were more likely to prescribe PAP and had higher self-reported competence in the method.\u003c/p\u003e \u003cp\u003eMajor barriers included time constraints, unclear procedures, limited training, inconsistent leadership, a lack of collaboration, a lack of consensus over the evidence base and usefulness of PAPs, and a lack of prioritization. Despite these challenges, there was strong interest among both personnel and managers in expanding PA counselling efforts.\u003c/p\u003e \u003cp\u003eThese findings align with previous research [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Despite national endorsement, PAPs are not yet fully integrated into Swedish routine healthcare [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], and in the current study, most healthcare personnel and managers expressed a desire for better conditions to work with this method.\u003c/p\u003e \u003cp\u003eThe qualitative findings confirmed that PAPs lack formal anchoring within healthcare settings. Many respondents perceived PAPs as tools that lacked added value, and some even questioned their appropriateness in certain patient interactions, fearing that they might feel intrusive or judgmental. This lack of consensus on the role and utility of PAPs undermines their legitimacy and signals a need for coordinated, legitimacy-building activities. Both healthcare personnel and managers requested improved regional and cross-sectoral collaboration with PAPs. Gustavsson et al. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] also stressed the importance of both a regional coordination function and local key players at the clinic level to support PAP efforts.\u003c/p\u003e \u003cp\u003eStaff turnover was also cited as a persistent barrier related to the need to retrain new staff while dealing with staff shortages. Similarly, time constraints were considered critical barriers by both managers and healthcare personnel, and many respondents indicated that PAPs were simply deprioritized in the face of other, more immediate demands. This is consistent with earlier studies highlighting that competing demands on staff time and operational pressures are significant challenges to the sustainability of health promotion interventions in clinical practice [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Interestingly, older healthcare personnel more often reported time constraints for PAP work, possibly reflecting differences in educational exposure to the method. However, Brorsson Lundqvist et al. [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] reported that more experienced physicians (\u0026gt;\u0026thinsp;10 years) were more likely to prescribe PAP than their less experienced colleagues were. Addressing staff turnover and time constraints through adequate managerial support, clear routines and ensuring time and resources to train staff as needed, not only at the beginning of implementation, could help integrate PAPs into daily practice.\u003c/p\u003e \u003cp\u003eAnother frequently cited barrier was the perceived unclear purpose of PAPs and perceptions of patients not being receptive to PAPs, particularly among managers. Healthcare personnel, meanwhile, highlighted internal barriers such as a lack of procedures and managerial support, as well as low competence. Few personnel were even aware of which colleagues were working with PAPs in their setting. These differing perceptions underscore the need for structured dialogue between management and personnel to align strategies and expectations.\u003c/p\u003e \u003cp\u003eDespite these challenges, the study identified several opportunities to strengthen PAP efforts. Most healthcare personnel showed confidence in PAPs\u0026rsquo; benefits and expressed a willingness to expand PA counselling. Access to simplified routines, ready-to-use patient materials (including in plain language and multiple languages), and improved collaboration with community activity providers were suggested as pragmatic next steps.\u003c/p\u003e \u003cp\u003eOur findings also highlight the need for greater integration of PAPs into public health strategies and for regional-level initiatives to foster collaboration with external providers, such as municipalities and community activity providers. This is particularly important in rural areas, where access to activities may be limited, making such collaborations even more crucial. The inclusion of PAP indicators in internal performance goals could further strengthen its role in routine care.\u003c/p\u003e \u003cp\u003eFinally, variations in perceptions of PAPs\u0026rsquo; evidence base suggest a need for targeted training. While some personnel were sceptical about the method\u0026rsquo;s long-term effectiveness, others expressed disbelief in its usefulness compared with other forms of PA counselling. Although evidence supports PAPs\u0026rsquo; ability to increase self-reported PA levels [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e], uncertainties remain, especially regarding sustained behavioural change [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Training efforts should therefore present a balanced view, acknowledging both the strengths and limitations of the method.\u003c/p\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and Limitations\u003c/h2\u003e \u003cp\u003eA key strength of this study is its use of a mixed-methods sequential design, which combines quantitative data with interviews to generate a rich understanding of PAP implementation [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Collaboration with regional stakeholders enhanced the study\u0026rsquo;s contextual relevance.\u003c/p\u003e \u003cp\u003eHowever, the relatively small sample size may limit rigorous statistical analysis and hence generalizability. Additionally, the risk of participation bias cannot be ruled out: those interested in PAPs may have been more inclined to participate, whereas others with negative perceptions may also have been motivated to voice concerns. Nevertheless, the presence of both perspectives in our findings helps mitigate systematic bias and build realistic insights. Future studies should consider including patient perspectives and conducting longitudinal assessments of implementation progress.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eImplications\u003c/h2\u003e \u003cp\u003eThis study underscores the importance of aligning priorities between healthcare personnel and management to strengthen PAP implementation. Embedding PAPs in routine practice requires leadership support, adequate training, and a shared understanding of their goals and benefits. Furthermore, fostering collaboration with community-based actors is crucial, especially in rural settings where healthcare resources are more limited. Technical tools and infrastructure must support\u0026mdash;not hinder\u0026mdash;the work of staff. Finally, evaluation mechanisms must be implemented so that PAP practices can evolve on the basis of feedback and real-world effectiveness. Efforts to implement PAPs will likely remain fragmented unless they are integrated into broader systems of accountability and public health promotion. Aligning PAPs with local care plans, incentive systems, and regional goals may provide the structural support needed for long-term success. These insights can inform strategies to integrate PAPs more effectively, both in Sweden and in other countries seeking to address physical inactivity and promote health equity.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn this study, PAPs were widely regarded as evidence-based and relevant by both healthcare personnel and managers, yet their use was inconsistent and poorly integrated into routine practice. The key barriers included (i) time constraints, (ii) a lack of shared understanding, (iii) weak engagement, (iv) insufficient leadership, and (v) minimal systematic follow-up. These challenges highlight that simply introducing an evidence-based method is not enough; success depends on shared understanding, clear roles, and active support within the healthcare system.\u003c/p\u003e \u003cp\u003eDespite these challenges, healthcare personnel expressed a desire to increase their involvement in PAP counselling, and managers wanted personnel to take a more active role. This shared commitment offers a promising foundation. However, divergent views on responsibilities and barriers underscore the need for improved communication and unified strategies.\u003c/p\u003e \u003cp\u003eTo address these issues, our study suggests clear prioritization by healthcare management, continuous training, and supportive organizational structures. Access to simplified patient materials, collaboration with community-based activity providers, and the appointment of local PAP coordinators were also identified as important steps. These measures should be embedded in a long-term public health strategy that is not treated as temporary initiatives.\u003c/p\u003e "},{"header":"Abbreviations","content":"\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003cp\u003eFYSS: Physical activity in the prevention and treatment of disease (Fysisk aktivitet i sjukdomsprevention och sjukdomsbehandling)\u003c/p\u003e \u003cp\u003eNPT: normalization process theory\u003c/p\u003e \u003cp\u003ePA: Physical activity\u003c/p\u003e \u003cp\u003ePAP: Physical activity on prescription\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003cp\u003eKV\u0026Aring;\u003c/p\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cem\u003eEthics approval and consent to participate\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eA formal ethical application was not submitted to the Swedish Ethical Review Authority, as the study qualifies as a quality development project conducted in accordance with the Health and Medical Services Act (1982:763), which does not require ethical review under the Swedish Ethical Review Act (2003:460). Furthermore, the study was entirely based on de-identified data, which also exempts it from mandatory ethical review. However, a formal ethical application was submitted to and reviewed by the Research Ethics Advisory Board at Mid Sweden University, which raised no objections (Dnr:2023/3163). Individual participants provided written informed consent to participate. This study adhered to the ethical principles outlined in the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConsent for publication\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAvailability of data and materials\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analysed during the current study are available from the corresponding authors upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCompeting interests\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis study received no external funding.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAuthors' contributions\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMM was the principal investigator (PI) and conceived the design of the study together with DS, AM, AH and TA. All the authors participated in the quantitative data collection. The interviews were conducted by DS, AM, AH and TA. MM, AH, AM and TA conducted the quantitative analysis, and DS conducted the qualitative analysis with assistance from MM. DS and MM drafted the manuscript, with contributions from AH, AM and TA. All the authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAcknowledgements\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank the health care personnel and managers who gave their time and shared their views with us. We would also like to thank Cecilia Andersson, the regional PAP coordinator, and Johan Börjesson, the director of the regional public health department.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWorld Health Organization. Global status report on physical activity 2022. Geneva: WHO; 2022. Available from: https://tinyurl.com/bde5k6t2\u003c/li\u003e\n\u003cli\u003eCosta Santos A, Willumsen J, Meheus F, Ilbaw A, Bull FC. The cost of inaction on physical activity to healthcare systems. Lancet Glob Health. 2023;11(1):32\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003ePublic Health Agency of Sweden (Folkh\u0026auml;lsomyndigheten). Rekommendationer f\u0026ouml;r fysisk aktivitet och stillasittande. 2023. Available from: https://www.folkhalsomyndigheten.se/livsvillkor-levnadsvanor/mat-fysisk-aktivitet-overvikt-och-obesitas/fysisk-aktivitet-och-stillasittande/riktlinjer-och-rekommendationer-for-fysisk-aktivitet-och-stillasittande/rekommendationer-for-fysisk-aktivitet-och-stillasittande\u003c/li\u003e\n\u003cli\u003eGuthold R, Stevens GA, Riley LM, Bull FC. Worldwide trends in insufficient physical activity from 2001 to 2016: a pooled analysis of 358 population-based surveys with 1.9 million participants. Lancet Glob Health. 2018;6(10):1077\u0026ndash;86.\u003c/li\u003e\n\u003cli\u003eUnited Nations. Goal 3: Ensure healthy lives and promote well-being for all at all ages. New York: United Nations; 2024. Available from: https://www.un.org/sustainabledevelopment/health/\u003c/li\u003e\n\u003cli\u003ePublic Health Agency of Sweden (Folkh\u0026auml;lsomyndigheten). Nationellt folkh\u0026auml;lsom\u0026aring;l och m\u0026aring;lomr\u0026aring;den. 2023. Available from: https://www.folkhalsomyndigheten.se/om-folkhalsa-och-folkhalsoarbete/tema-folkhalsa/vad-styr-folkhalsopolitiken/nationella-mal-och-malomraden/\u003c/li\u003e\n\u003cli\u003eCommission for Equity in Health (Kommissionen f\u0026ouml;r J\u0026auml;mlik H\u0026auml;lsa). N\u0026auml;sta steg p\u0026aring; v\u0026auml;gen mot en mer j\u0026auml;mlik h\u0026auml;lsa: F\u0026ouml;rslag f\u0026ouml;r ett l\u0026aring;ngsiktigt arbete f\u0026ouml;r en god och j\u0026auml;mlik h\u0026auml;lsa. Slutbet\u0026auml;nkande (SOU 2017:47). 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Physical Activity on Prescription with Counsellor Support: A 4-Year Registry-Based Study in Routine Health Care in Sweden. Healthcare. 2018;6(2):31.\u003c/li\u003e\n\u003cli\u003eBrorsson Lundqvist E, Praetorius Bj\u0026ouml;rk M, Bernhardsson S. Physical activity on prescription in Swedish primary care: a survey on use, views, and implementation determinants amongst general practitioners. Scand J Prim Health Care. 2023;42(1):61\u0026ndash;71.\u003c/li\u003e\n\u003cli\u003eBoman C, Bernhardsson S, Lauruschku K, Lundqvist S, Melin K. Prerequisites for implementing physical activity on prescription for children with obesity in paediatric health care: A cross-sectional survey. Front Health Serv. 2023;2:1102328.\u003c/li\u003e\n\u003cli\u003eLundqvist S, B\u0026ouml;rjesson M, Cider \u0026Aring;, Hagberg L, Ottehall CB, Sj\u0026ouml;str\u0026ouml;m J, Larsson ME. 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Effectiveness of physical activity interventions delivered or prompted by health professionals in primary care settings: systematic review and meta-analysis of randomised controlled trials. BMJ. 2022;376:e068465.\u003c/li\u003e\n\u003cli\u003ePosadzki P, Pieper D, Bajpai R, Makaruk H, K\u0026ouml;nsgen N, Neuhaus AL, Semwal M. Exercise/physical activity and health outcomes: an overview of Cochrane systematic reviews. BMC Public Health. 2020;20:1724.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-primary-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"famp","sideBox":"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12875","title":"BMC Primary Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Health promotion, Healthcare, Implementation, Mixed-Methods design, Normalization process theory, Physical activity on prescription, Primary healthcare","lastPublishedDoi":"10.21203/rs.3.rs-6869061/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6869061/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003ePhysical inactivity is a risk factor for noncommunicable diseases and premature mortality. Physical activity on prescription (PAP) is a recommended method for promoting physical activity in Swedish primary healthcare and in other European countries, but its implementation varies across regions. This study aimed to identify barriers and strategies to strengthen PAP implementation in a region with low prescription rates, as perceived by healthcare personnel and managers in primary healthcare.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA mixed-methods study with an explanatory sequential design was conducted (spring 2024) in a geographically dispersed region of Sweden. The digital surveys were completed by 75 healthcare personnel and 18 managers. Uni-, bi and multivariate analyses were used for quantitative data, followed by semistructured interviews (n\u0026thinsp;=\u0026thinsp;14) analysed with qualitative content analysis, guided by normalization process theory (NPT).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThirteen percent of healthcare personnel prescribed PAP regularly. Physiotherapists prescribed PAP more often than other professionals did (odds ratio [OR] 4.0, confidence interval [CI] 1.01\u0026ndash;15.83). Barriers included time constraints, lack of guidelines, knowledge and low managerial prioritization. Compared with those aged\u0026thinsp;\u0026le;\u0026thinsp;45 years, personnel aged\u0026thinsp;\u0026ge;\u0026thinsp;46 years were more likely to perceive time constraints (OR 3.6, CI 1.27\u0026ndash;10.16) when adjusted for gender and profession. Compared with males, females (n\u0026thinsp;=\u0026thinsp;36/41, 88%) expressed more frequent trust in evidence for PAPs (n\u0026thinsp;=\u0026thinsp;8/14, 57%), p\u0026thinsp;=\u0026thinsp;.013. Only 38% (n\u0026thinsp;=\u0026thinsp;28) had received PAP training. Divergent perceptions between personnel and managers were noted regarding leadership engagement, personnel competence and patients\u0026rsquo; receptiveness to PAPs. However, a majority expressed a desire to increase physical activity counselling. The areas of improvement included a shared understanding of PAPs, training, clear leadership and support structures, and systematic evaluation. Collaboration with activity providers and access to adapted patient materials were also identified as mitigating measures.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eStrong interest in PAPs among healthcare personnel and managers indicates favourable conditions for sustainable implementation, provided that training to build a shared understanding and agreement around PAPs (coherence), customized resources and structured processes (cognitive participation), clear leadership commitments to facilitate allocated resources (collective action), and PAPs coordinated across organizational levels to support consistent monitoring and evaluation (reflexive monitoring) are all in place.\u003c/p\u003e","manuscriptTitle":"Barriers and Implementation strategies for Physical Activity on Prescription (PAP): Healthcare personnel and Management Perspectives in Sweden—An Explanatory Sequential Study Design","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-27 10:21:05","doi":"10.21203/rs.3.rs-6869061/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-09-01T18:14:31+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-28T18:55:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"252821470054568301183255852496265846950","date":"2025-08-28T16:21:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"54614331537102160412481431816151400795","date":"2025-07-06T18:12:51+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-02T18:53:48+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"241673593185285984646336426179525357835","date":"2025-06-24T22:23:10+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-24T18:28:22+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-16T08:57:08+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-14T13:35:20+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Primary Care","date":"2025-06-14T13:32:27+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-primary-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"famp","sideBox":"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12875","title":"BMC Primary Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b7717548-0acd-48e7-8eec-cea4b3fb5618","owner":[],"postedDate":"June 27th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-10-13T16:00:23+00:00","versionOfRecord":{"articleIdentity":"rs-6869061","link":"https://doi.org/10.1186/s12875-025-03038-y","journal":{"identity":"bmc-primary-care","isVorOnly":false,"title":"BMC Primary Care"},"publishedOn":"2025-10-06 15:57:26","publishedOnDateReadable":"October 6th, 2025"},"versionCreatedAt":"2025-06-27 10:21:05","video":"","vorDoi":"10.1186/s12875-025-03038-y","vorDoiUrl":"https://doi.org/10.1186/s12875-025-03038-y","workflowStages":[]},"version":"v1","identity":"rs-6869061","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6869061","identity":"rs-6869061","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}