Table 5 Behavioral diagnosis and theoretical domain mapping

Capability - Physical

[E] Healthcare professionals are more likely to have physical activity consultations if they are active themselves [75, 78, 99, 100]

[E] Training on how to use resources will improve utility [21, 35, 79]

Physical skills

Information and resources supporting the integration of activity into daily life should be as applicable to healthcare professionals as patients [78, 99]

Supporting resources should include training capability on the skills required for good quality conversations about physical activity [101,102,103,104]

Capability -Psychological

Psychological barriers to engagement include [35, 75, 79, 105]:

[B] Uncertainty around advice for specific conditions

[B] The perception that other lifestyle factors are easier to address and more important

[B] Physical activity and behavioral change education is generally limited [46, 106,107,108,109,110,111]

Knowledge

Resources should address the widely reported deficit in knowledge on physical activity in the management of long term conditions [21, 31, 35, 99]

Cognitive and interpersonal skills

Traditional transactional medical consultation models do not transfer well into behavioral change discussions, so solutions need to promote and support person-centered behavioral change conversations [33, 63, 69, 103, 105, 112]

Memory attention and decision processes

Clinical staff already have many tasks and objectives during a consultation. Wherever possible, interventions should be structured in such a way that they can fit naturally into clinical workstreams in a time-sensitive fashion [35, 113]

Opportunity - Physical

[B] Actual and perceived lack of time are fundamental barriers to physical activity conversations [21, 35, 74, 75, 100, 114]

[E] Computers are fundamental to healthcare delivery, so freely available online solutions are likely to increase accessibility

[E] Signposting of resources and support structures need to be clear [21, 101, 102, 104, 115]

[E] Printable elements such as campaign posters and patient leaflets should be easily and freely available [60, 79]

[E] Pathway support will benefit from tools to facilitate physical activity behavioral change [21, 100, 115]

Environmental context and resources

Lack or perceived lack of time must be addressed upfront [20, 27, 66, 100]

Busy work environments and service delivery pressures often impact continual professional development (CPD), including taking on new knowledge and learning new skills. Successful training solutions will support the delivery of routine care and CPD requirements [20, 27, 66, 100]

Few healthcare environments are activity permissive. Resources for system support and promoting cultural change are likely to help clinical staff be more active [99]

Clinical staff are not clear on where they can get good quality physical activity materials and resources. Memorable and easily accessible signposting resources are required [102, 116, 117]

Opportunity - Social

[E] Involving professional bodies and disease area specialists in the design and development of solutions supporting clinical practice will improve credibility [100, 118]

[E] Peer support from other healthcare professionals and the workplace environment increases opportunity [100, 118]

[E] Peer-group supported online learning and ambassador network has the potential to improve physical activity delivery by developing lasting social opportunities [100]

[E] Prompts coming from patients themselves will encourage HCPs to reflect and prioritize physical activity in consultation [112]

Social influences

Physical activity is currently a lower priority in routine clinical practice than other behavioral components such as smoking, drinking alcohol and eating [75]. As a result, clinical pathways (except for a few notable exceptions, such as cardiac rehabilitation) do not promote normative peer group behaviors around physical activity conversations. Resources targeting specific conditions may help to clarify the role of physical activity in general care pathways [83]

Motivation - Reflective

[E] Healthcare professionals believe that conversations about physical activity are important [21, 105]

[B] Many healthcare professionals recognize physical activity as important but do not feel they have the knowledge or confidence to counsel patients effectively [21, 31, 35, 99, 105]

[B] Healthcare professionals frequently avoid talking about physical activity for fear of provoking resistance, so it is likely building confidence in techniques that avoid generating resistance behaviors and promote positive experiences will improve motivation [21, 66, 75, 78]

[E] Evidence should be published by a trustworthy source as healthcare professionals consider this essential to believing it. Ideally the evidence base will also be presented in an easily accessible format to improve engagement [119]

[B] Interventions are required to help build clinician self-efficacy [35, 79]

[B] Perceived lack of success

Social/ professional role & identity

Supporting patients to lead physically active lives lies at the heart of healthcare and therefore is a responsibility of all healthcare professionals. Identifying role-specific intervention strategies and re-enforcing when and where it is a priority for healthcare professionals will help address this [11, 35, 75, 116, 120]

Fostering a leadership culture amongst colleagues by giving early adopters resources and confidence in their knowledge can help drive change [121, 122]

Beliefs about capabilities

Self-efficacy is a relevant intervention target since the confidence of a healthcare professional in their ability to impact upon patient behavior and trust in support from the healthcare system is associated with improved frequency and quality of physical activity conversations [101,102,103,104]

Those who report physical activity behavior change conversations negatively seldom initiate them. Resources helping build self-efficacy through reflective practice can help improve this [11, 21, 35, 75, 79, 100]

Optimism

Healthcare professionals who discuss physical activity frequently with patients generally feel confident they will have an impact. Empowering these individuals to influence their colleagues who do not frequently discuss physical activity and do not believe they will make a difference may help improve optimism [11, 35, 75, 100]

Intentions

Healthcare professionals do not always see it as their role to influence physical activity, but a system-wide approach requires appropriate intervention at all opportunities. Solutions should be flexible enough to help clinicians in all roles make a constructive contribution [35, 75, 116, 120]

Goals

Clinical delivery targets and guidelines drive goals in clinical practise. Facility to generate physical activity metrics may assist this service development [27, 101]

Healthcare professionals benefit from individual goals for professional development when developing new skills

Beliefs about consequences

Healthcare professionals who believe their conversations on physical activity are well-received talk more frequently about physical activity. Patient-led prompts can help to improve this [112]

Motivation - Automatic

[E] Conversations on physical activity around the management of long-term conditions should become habitual for healthcare professionals. Contributing to this is confidence in conversations about physical activity, demand from patients, the behavior of peers and demands of clinical practise

[E] Systematic prompts in medical records systems are beneficial for building habits

[E] Solutions should meet expected standards of practice, guidelines and best-practise management strategies [123]

Reinforcement

Promoting patient initiation of conversations on physical activity and peer group discussions/learning incentivizes conversations and reinforces the importance with healthcare professionals [119]

Emotion

Physical activity behavior change conversations that go badly can lead to patients becoming upset, particularly if they feel judged. Healthcare professionals who have had such unpleasant experiences frequently avoid future conversations in the fear they may end up the same way [66, 78] Training in counselling skills throughout undergraduate and postgraduate education can help improve this [102, 124]