Table 2 Summary of barriers to physical activity conversations in clinical practice

Time

Time is the most commonly reported barrier to physical activity conversations in clinical practice by all healthcare professionals [17,18,19, 33, 71,72,73,74,75,76,77,78,79,80,81,82]. Directly addressing time concerns is vital to improving conversations about physical activity in healthcare [22, 73, 82, 83] particularly when targeting doctors [84]. There is a delicate balance between physical activity contacts and other aspects of clinical management when delivering frontline clinical services, necessitating flexibility in any successful approach [22, 85]. Addressing both the barrier of time and appropriate allocation of resources reflects recommendations by NICE in the UK for “very brief, brief, extended brief and high intensity” behavioural change interventions [45]. Other systems reporting on approaches to physical activity consultation in practice support this approach [27, 86].

Knowledge

Healthcare professionals may lack knowledge about physical activity, and others consider the evidence base insufficiently robust [72, 81]. Those who lack knowledge ask patients about physical activity less frequently than those who consider their knowledge sufficient [76]. Although many feel comfortable giving general advice, healthcare professionals are less confident addressing detailed physical activity advice [84] and inhibited by the possibility of patients experiencing adverse events following their advice [87]. This deficit reflects inadequate training both in undergraduate and postgraduate curricula [23, 88,89,90].

Skills

Healthcare professionals perceive conversations around physical activity and supported self-management as important [84, 91] but those who lack confidence in their skills give physical activity advice infrequently [16, 84]. Furthermore, those who counsel patients regularly expect to be moderately or very successful, whereas those who seldom initiate physical activity discussions rarely expect them to make a difference [75].

Behaviour change skills are not traditionally taught in undergraduate medical education, and resistance to employing these skills is commonplace throughout the medical profession [32]. Attempts to integrate behaviour change skills into the undergraduate syllabus have been promising, with demonstrable improvement in understanding behaviour change principles and improved skills [32, 92]. Postgraduate training in communication skills positively impacts clinical outcomes and individual knowledge and expertise [93].

Consultation structure

The lack of a structured approach to physical activity conversations is a common barrier to effective communication amongst nurses [77]. Doctors do not appear to lack structure but are prone to taking an experimental approach to conversations, selecting behaviour change techniques arbitrarily without rationale or a coherent strategy [32].

Consultation model

Adapting routine consultations to a collaborative model will likely improve behavioural change support [5]. Healthcare professionals do not always realise when they fail to prioritise the individual’s agenda and frequently adopt a style of practice, such as diffidence or deflection, that delegitimises behaviour change talk in consultation [12]. One-sided, transactional conversations dominate this approach, failing to explore the individual’s perspective [12]. Training that focuses on building positive attitudes, self-efficacy and intentions may provide an effective strategy to address this [91, 94].

Healthcare professional-patient relationship

A lack of success, including bad experiences, during behavioural change conversations can demoralise healthcare professionals and prompt them to disengage from future attempts [32]. Accordingly, negative patient attitudes make healthcare professionals less likely to discuss physical activity with them [22, 84, 87]. Healthcare professionals perceive good interpersonal relationships as being vital in addressing behavioural change [87]. Paradoxically, positive relationships can also be a barrier to physical activity conversations since healthcare professionals may avoid them for fear of causing offence and damaging the relationship [32, 95].

Contrary to the expectation of many healthcare professionals, patients are receptive to behavioural change conversations in routine medical consultation [87]. Patients value collaborative discussion, may be resistant to a ‘preaching’ style and are most receptive when physical activity is likely to benefit their long-term medical conditions [87].

Healthcare professionals’ physical activity behaviour

Healthcare professionals’ own physical activity behaviours are a strong determinant of consultation behaviour, with less active individuals up to four times less likely to talk to people about physical activity in clinical practice [78, 96, 97].

Patient engagement

Perceived lack of motivation to change behaviour is a commonly cited barrier to physical activity conversations by healthcare professionals [21, 84]. Patients themselves welcome conversations around behaviour change [87]. Interventions encouraging patients to initiate behavioural change conversations have demonstrated success in changing healthcare professional behaviour [70, 87, 98].

System priorities

The lack of a whole system approach to integrating physical activity into routine care makes success unlikely [5, 15]. Practitioners are only likely to engage in behaviour change work if their systems value and promote it [12]. Lack of reimbursement and financial incentivisation is common but may be powerful facilitators for physical activity interventions [33, 82, 84]. It is unclear if incentivisation results in long-term change [93].

A common problem with physical activity interventions in clinical practice is that they frequently sit outside routine care pathways and lack system integration, compromising delivery [82]. Adequate resourcing, strong leadership and good communication are essential strategies to support the adoption of new processes in clinical services [70]. Systems supporting inter-professional collaboration and addressing local barriers to change positively affected care processes and patient outcomes [33, 93].

Education strategies

Despite being the most frequently used intervention [70, 99], printed education materials are likely ineffective in influencing healthcare professional behaviour if delivered passively [98, 100, 101]. The impact of educational workshops introducing physical activity is mixed [22]. Education strategies are likely to be most effective in changing healthcare professional behaviour if implemented with active strategies as part of a multifaceted intervention [93, 101,102,103]. Professional engagement and knowledge acquisition are improved when information is summarised and presented concisely and in an accessible format [104].

Supporting resources

A lack of information, educational resources and signposting opportunities for healthcare professionals and patients limit physical activity initiatives [88, 105, 106]. Structured and supported education, engagement and resourcing in primary care can increase physical activity contacts and have a widespread impact on organisations supporting physical activity [107]. The intention to promote physical activity is a strong predictor of consulting behaviour. Targeting professional attitudes and social norms are a promising area for success [108]. Positive messaging on best practice from subject area experts and opinion leaders promotes the uptake of best practice [93].