Physical activity promotion in primary care: Health professional and patient views on connecting primary care patients with community-based physical activity opportunities

Background Inconclusive evidence in support of referrals from health professionals to gym-based exercise programmes has raised a concern for the roll-out of such schemes and highlights the importance of developing and maintaining links between primary care settings and community-based opportunities to improve physical activity levels. This study aimed to identify methods of connecting primary care patients to community-based physical activity opportunities, using the example of jog scotland , and to explore what factors can facilitate this connection. Methods We conducted a qualitative exploratory study utilising semi-structured interviews with primary care patients (n=14) and health professionals (HP) (n=14) from one UK National Health Service (NHS) board. We analysed the transcripts separately for patients and HPs using thematic analysis and synthesised them for potential methods of connection. Sub-themes for patients and HPs were mapped onto relevant components of the capability, opportunity, motivation behavioural (COM-B) model and theoretical domains framework (TDF) to identify barriers and facilitators for connecting primary care to community jog scotland groups. Results Three potential methods of connecting patients to community-based jog scotland groups were identified: informal passive signposting, informal active signposting, and formal referral or prescribing. Barriers and facilitators to connecting patients to jog scotland groups fell into five TDF domains for HPs and two COM-B model components for patients. Conclusions Our findings suggest that for patients, the acknowledgement and raising of the topic of physical activity improvement by their HP can help to justify as well as facilitate and motivate action to change. The workload associated with connecting patients to community-based opportunities is central to the implementation by HPs. Resource solutions (e.g. intermediary person or community information hub) and social support opportunities for patients (e.g. meet and greet) can provide patients with a greater variety of physical activity options and the vital information and support for connecting with local community-based opportunities, such as jog scotland .

launched in 2002 through the support of the Health Education Board for Scotland, Scottish Athletics and sportscotland. jogscotland was designed to encourage people to gradually increase their activity levels to help improve their health and well-being. Currently, over 500 groups exist across Scotland.
By providing training to individuals to become jog leaders and set-up their own local jogging group, these volunteer-led local groups have emerged and grown to support thousands of people to get more active and stay more active, often embedding the NHS 'Couch to 5K' programme (13). The continued growth of these jogscotland groups may be attributed to the inclusive and supportive nature described by members of these groups, together with their community-centred locality and low-cost structure (14).
Current research evidence suggests that barriers for physical activity referral by primary care health professionals includes: a lack of time and incentive (15), a lack of expertise, medico-legal concerns and responsibility (16). However, investigation into options for connecting patients to communitybased opportunities and the views of primary care patients on physical activity promotion to community-based physical activity opportunities, is currently lacking. Thus, using the example of jogscotland, the aim of this study was to explore primary care health professional and patient views regarding: 1) potential methods of connecting primary care patients to community-based physical activity opportunities; 2) barriers and facilitators to employing the identified methods of connection.

Methods
This study was part of a larger project aiming to design and test the acceptability and effectiveness of implementing a process of connecting primary care patients to local jogscotland groups as a community-based approach to increase physical activity (local jog leaders and a member of jogscotland were our advisers on the larger project). In combination with a realist scoping review of the literature on the existing methods employed to connect primary care patients to physical activity opportunities, we conducted an exploratory qualitative study using semi-structured interviews with primary care patients and health professionals in Scotland. The findings from both the review and the qualitative study were utilised to inform the design of a feasibility study.
Health professionals (HP) with a patient-facing role working within NHS primary care general practices 5 in the Fife area (East Scotland) were invited to take part in the study through email invitation disseminated by the NHS Research Scotland Primary Care Network. Patient participants were identified as being registered at a general practice in Fife and recruited utilising SHARE, the Scottish Health Research Register (17). Opportunistic recruitment of patients was additionally conducted via face-to-face advertisement at a local practice by a member of the research team. A target sample of 15 patient and 15 health professional interviews was identified as an appropriate sample size to provide the opportunity for the saturation of themes during data analysis (18,19). Maximum variation sampling was used for patient recruitment to include male and female patients, different age groups (18-30; 31-40; 41-50; 51-60; 61-70; 70 + years old), and patients from different geographical locations across Fife. Patients were excluded from participation if they had been medically advised to refrain from taking part in physical activity.
Semi-structured interviews were conducted either face-to-face at a suitable location or via telephone, depending on participant preference. In line with ethical guidelines, the participant's written informed consent was obtained prior to commencing the interview. The interview guides were developed by the research team and reviewed by our jogscotland advisors. The guide included demographic questions (age and gender) and self-reported of physical activity levels and were informed by the capability, opportunity and motivation model of behaviour (COM-B), the central component of the Behaviour Change Wheel (20). The COM-B model has previously assisted exploration and understanding of health-related behaviour and healthcare professional practice (21)(22)(23). The interview guides also included specific open-ended questions about the acceptability and implementation of methods of connecting patients to jogscotland groups, as a working example of connecting primary care patients to community-based physical activity opportunities.
Interviews were digitally recorded and conducted by two researchers (SAC, RHR) experienced in qualitative methods, and guided by interview guides. Coded audio files were transferred to a thirdparty transcription service and transcribed verbatim. Coded transcripts were analysed utilising NVivo 11.0 software (24) which aided in the management, coding and collation of the data.
Data analysis was conducted separately for the HP and patient transcripts, analysing for views 6 regarding potential methods of connecting primary care patients to the community-based physical activity opportunities such as jogscotland. To establish an understanding of the barriers and facilitators to physical activity promotion to community-based opportunities for HPs, the data was analysed by coding instances within the transcripts in line with the COM-B model components and mapping onto relevant Theoretical Domains Framework (TDF) domains (25) using reflexive thematic analysis (26). The fourteen-domain TDF was deemed suitable as it prompts an analysis of social, environmental, cognitive and affective influences on health professional practice (27). It links directly to the components of the COM-B model and provides an integrative theoretical framework incorporating individual and organisational determinants of behaviour previously proven useful for understanding the implementation of evidence-based practice and research (27,28). The data was analysed utilising a deductive thematic analysis approach guided by the TDF domains for the emergence of themes. The data was then analysed utilising an inductive approach to thematically generate explanatory sub-themes within the identified domains. Patient transcripts were analysed in a similar approach utilising deductive coding for instances within the transcripts in line with the COM-B model components and then utilising an inductive approach to generate sub-themes.
One member of the research team (SAC) conducted the coding of all transcripts, mapping of subthemes, and data synthesis. A second team member (GO) independently analysed a sample of the interviews (20% randomly selected transcripts from each HPs and patients) to ensure appropriateness of coding and mapping.

Results
A total of 28 individuals (n=14 HPs and n=14 patients) participated in the qualitive interviews therefore nearly reaching our target sample size of 30 and achieving saturation of themes. Participant demographics are presented in Table 1. Participants were represented across genders for both HPs and patients. A diverse age range was achieved for patients (33-72yrs) and smaller range for HPs (38-56yrs). HP participants included both general practitioners (GP) (64.3%) and practice nurses (35.7%).
Self-reported physical activity levels identified the majority of HPs (92.9%) and patients (57.1%) describing being active at least 3 days per week. Both patients and HPs were asked about whether they had previously or regularly had discussions about physical activity with their HP/patients. HPs mainly stated this occurring 'often', 'all the time' or even daily, however, for the majority of the patients they answered that the HP had not mentioned improving physical activity that they could remember but did frequently describe conversations about body weight that often linked to physical activity.

Connecting primary care patients to jogscotland: Professional and patient views regarding potential methods
Interviews with both HPs and patients revealed various potential methods of connecting patients to community-based jogscotland groups. We have categorised these into three: informal passive signposting, informal active signposting, and formal referral/prescribing, based on the type and level of workload associated with the processes of connection for the HP. Each of these methods can be implemented in multiple ways ( Figure 1) and for the patient, can involve varying levels of associated 8 workload, that is, low level; -following referral they are contacted by an intermediary person/third party with more details, or a higher workload level; -that is, patient self-refers to seek further information following signposting or prescribing. Both patients and HPs acknowledged that advertising local physical activity opportunities such as jogscotland could easily be achieved at the GP practice as well as throughout the wider community.

Professional and patient views regarding barriers and facilitators to the identified methods of connection
For both HPs and patients, the barriers and facilitators to connecting patients can be described to arise in two contexts: a) within the raising of the topic of physical activity and b) in connecting patients to the physical activity opportunity. Views from HPs and patients are presented separately in accordance to their analysis approach.

Health Professional Views
For HPs, the barriers and facilitators for connecting patients to physical activity opportunities, such as

Memory, attention and decision processes
For the HPs, their real-time decision-making on whether to raise the issue of physical activity with their patients was guided by how the interaction unfolded and their rapport with the patient during the consultation. Many HPs describe that their decision on whether to raise the topic of physical activity improvement involved waiting for an opening or opportunity when the patient establishes for themselves that physical activity and lifestyle factors could help improve health complaints. This patient-led raising of the topic then acts as the opening opportunity for the HP: Thus, HPs are the main instigators of discussions concerning physical activity, and whether or not they decide to do so is often determined by their perception of the patients' receptivity and openness to the topic.

Beliefs about consequences
Many of the HPs expressed that their decision regarding whether or not to discuss physical activity with their patients depended on their beliefs about the patients' engagement and confidence in improving their physical activity levels. In particular, many HPs discussed that their perception that patients would action their suggestion to improve their own health through increased physical activity was a significant consideration when deciding whether or not to raise the issue during a consultation: The HPs often discussed both that the responsibility lies within the wider community and society as well as with the patient who needs to take ownership for their own health.
For some HPs, there was a medico-legal concern for connecting patients to local opportunities such as jogscotland, where the HPs lack of knowledge about the suitability and content of these local physical activity groups led to concerns:

Patient views
For patients the barriers and facilitators identified fell within the COM-B components of motivation and opportunity.

Motivation
The Participants in some of the interviews suggested that the opportunity to meet with organisers and members of a local jogscotland group could allow patients to 'meet and greet' with local physical activity groups in their area. This potential option was then raised by researchers in latter interviews with patients to ask their views. Patients often described that a 'meet and greet' (potentially held at a local community location or even the health centre/healthcare practice) could provide them the opportunity to ask questions of what is involved and to meet with people before turning up for the first time -a barrier often mentioned by many individuals during the interviews when they consider starting or turning up to a physical activity opportunity:

Discussion
To our knowledge, this is the first study to focus on identifying potential methods of connecting primary care patients to local community-based physical activity opportunities, such as jogscotland, and the barriers and facilitators to employing those methods of connection. We identified three types of methods of connecting primary care patients to local jogscotland groups: informal passive signposting, informal active signposting, and formal referral or prescribing. Previous quantitative (15,(29)(30)(31) and qualitative studies (16,32) in the UK have highlighted that barriers to physical activity promotion by health professionals include: a lack of time, lack of incentive, lack of knowledge to advise patient, belief that patients wouldn't engage with the advice, appropriateness of discussing during consultation, and medical-legal aspects and responsibility. Our study's findings confirm many of these barriers for HPs which fall within the five domains of the TDF: knowledge; memory, attention & decision processes; environmental context and resources; social/professional role and identity; beliefs about consequences. This study further builds upon this knowledge by providing an understanding of patient views on the barriers and facilitators, as well as reveal some potential solutions suggested by the HPs and patients for overcoming perceived barriers to connecting patients.
In the present study, HPs and patients discussed various potential methods of connecting primary care patients to community-based physical activity opportunities, with assorted ways of implementing each method suggested. What is apparent from the discussions is that there was no single method that was deemed 'best'. Both patient and HP participants highlight the necessity for a variety of means to make connections to accommodate individual preferences. These methods of connection range in their level of health professionals' workload or involvement, from a passive signposting approach at the practice level, a light touch signposting approach, to a more formal prescribing or referral. Importantly, within and across these methods the level of workload for the patient can vary from a low level of referral and follow up (i.e. direct referral to a physical activity group organiser or other intermediary person who then contacts the patient), to a higher-level workload of self-referral and follow-up (i.e. signposted or indirectly prescribed physical activity but the patient takes action to seek further information from community physical activity groups).
The diversity of methods and workloads for both 'actors' in physical activity promotion and connection reflects individualistic needs and wants as well as beliefs related to whose responsibility it is to 'do something' about improving physical activity levels. Both HPs and patients highlighted that linking physical activity promotion with clinical consultation is a key opportunity for potential and opportunistic intervention. Furthermore, many HPs and some patients acknowledged that the responsibility for increasing physical activity should not be limited to the HP and their professional role, rather it also lies within individuals and with wider society and societal norms about selfmanagement. These findings mirror those previously found in qualitative studies conducted with HPs discussing the limitations of exercise referral and exercise on prescription schemes (16,33). This body of work together with our findings reiterate that there is a shared responsibility in health promotion with HPs and patients alike indicating a desire and acceptance of connections from HPs to non-medical support for self-management also known as social prescribing (also known as community referral).
Mirroring previous findings (16,34), both HPs and patients see the role of the HP as a facilitators, but should not be dictators, in physical activity promotion due to the perception of the HP as a key person of influence with professional responsibility. However, patients often contradicted themselves during discussions in describing that they 'did not want to be parented' but also reflected that being encouraged or directed by their HP to make changes to their physical activity and/or lifestyle habits was an influential and motivational factor in making changes. In effect, what they were describing was a need to hit a fine balance between directing and suggesting in a supportive manner and being too directive and prescriptive, an important aspect for implementation of behaviour change techniques (35). With HPs acting as facilitators and motivators, it was apparent that for patients the acknowledgement and action of the HP raising the topic of physical activity improvement provided a legitimacy to the issue and an opportunity to do something about the problem. We have categorised the identified methods of connecting into three; informal passive signposting, informal active signposting, and formal referral/prescribing to reflect the implementation workload for the HP.
However, from a patient's perspective the very nature of the HP connecting them to physical activity opportunities across any means of signposting or referral, was seen as 'formal' acknowledgement of the problem. The three modalities are not mutually exclusive and all three may be beneficial for some people.
The HP-patient relationship and the manner in which HPs raise the topic of physical activity with their patients was also an important consideration raised within discussions and linked to how the HP can act to motivate or facilitate physical activity promotion. Timing in particular was of key importance, 'getting the patient at the right time' and open and motivated (16,32) to the suggestion of improving their physical activity was a focal part of the HPs decision-processing. How the topic was raised and linked to patient's specific health conditions was central to the patient's acceptance and openness to the topic, supporting previous patient views on health promotion in healthcare (34). Within any HPpatient conversation about improving physical activity, both patients and HPs felt that providing patients with tangible physical activity opportunities to look in to, in contrast to 'you should get more exercise', was a preferable and more effective approach. However, for the HPs accessing or having the knowledge of different local physical activity groups and opportunities was a major barrier to being able to achieve this, a barrier previously identified for health promotion in primary care (36).
Being able to provide up-to-date information on an assortment of physical activity groups, together with the knowledge of what these different groups do and who they are suitable for was sought. HPs, with concern about the medico-legal aspects of connecting patients to local activity groups about which they were not familiar, identified that a solution to their lack of time and knowledge of the different opportunities would be for an intermediary person (e.g. practice champion, community hub, or link worker) to be available for the local area in which they could signpost or formally refer patients towards. Similar to Leenaars et al (36), the link worker or community hub solution was seen by HPs to be able to bridge the connection between primary care and third party groups, providing the patients with more detailed information on the variety of options available in their local area. This type of resource was also seen to be a key solution to alleviate the time pressures HPs experienced within a consultation to discuss specific physical activity opportunities and supported the consensus that 20 patients can also self-refer to this type of resource and take responsibility for their own health improvement.
It was acknowledged by both HPs and patients that for many individuals having social support to begin, and to maintain, any physical activity improvement is fundamental to success. With this in mind, HPs and patients discussed that an opportunity to meet 'people like me' who are also trying to engage with a physical activity opportunity would be a potential supportive solution that the practice and wider community could be involved with. In particular, providing an opportunity to 'meet and It is crucial to highlight however that the sample of HPs interviewed for this study self-reported frequent physical activity levels and thus may be more likely to signpost/refer their patients to physical activity opportunities (15). Furthermore, the HPs taking part in this study may not be a truly representative sample of HPs throughout the NHS due to their keen interest in the study and topic of promoting physical activity. Equally there may have been a response bias with patients who were also interested in the topic of physical activity and promotion, thus caution should be implemented in generalisation of the findings.

Conclusions
Physical activity promotion using connection to community-based opportunities was seen by both primary care HPs and patients to be of value. The identified methods of connection from our study reflects the varied associated workload levels for the HP, from passive and no direct involvement, a light touch approach of informal active signposting, to formal referral or prescribing. Across and within these methods there was some variability in the patient's level of associated workload (i.e. from low level where connections are made for them to a higher level, where they self-referral to seek further information.) These varied methods of connecting highlight the diverse and individualist needs and wants of HPs and patients alike for physical activity promotion opportunities. Our findings suggest that supporting HPs to deliver physical activity promotion must focus on resource solutions, examples such as access to an intermediary person or community information hub, and practice-linked social support for patients through meet and greet, or buddy systems. These aspects were seen to be central in giving patients greater variety of physical activity options and the vital information and support to connecting with these local community-based opportunities.

Ethical approval and consent to participate
Ethical approval for the study was obtained from NHS Research Ethics Committee and NHS Fife

Consent for publication
The views expressed by the participants was obtained following written informed consent. This consent included the use of anonymous quotations from interviews after all identifying information was removed from interview transcripts.

Availability of data and materials
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Competing interests
The authors declare that they have no competing interests.

Funding
This study was supported by the NHS Fife Endowment Fund Grant which was awarded as part of a larger project (FIF142). The funding body had no impact on the design of the study and collection, analysis, and interpretation of data or in writing of the manuscript. The views expressed are those of the authors.

Author Contributions
Conceptualization  HP barriers and facilitators to connecting patients to community-based physical activity opportunities.