Understanding the barriers and facilitators to successful behaviour change in self-management within the context of Pulmonary Rehabilitation using a Critical Realist approach

Butler, Frances Helen (2023) Understanding the barriers and facilitators to successful behaviour change in self-management within the context of Pulmonary Rehabilitation using a Critical Realist approach. Doctoral thesis, Northumbria University.

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Abstract

Introduction
This study aimed to explore the opportunities and challenges associated with behaviour change in self-management within the context of Pulmonary Rehabilitation using the principles of Critical Realist philosophy. Self-management in chronic respiratory disease and long-term conditions management is a challenging area of healthcare. A complex interplay between issues surrounding adherence, self-management and ultimately behaviour change makes research and clinical practice in this area a challenge. The relationship between the physical and psychological health in individuals with chronic respiratory disease requires an individualised and holistic approach to management of the disease symptoms.

Methods
A qualitatively-driven mixed-methods approach was employed using focus groups and survey methods. A series of focus groups were conducted with a purposive sample of individuals who had recently completed a local Pulmonary Rehabilitation programme (2 groups, total 4 participants), Healthcare Professionals (2 groups, total 8 participants) and Members of the Breathe Easy support group (2 groups, total 8 participants). Themes were described using the Thematic Networks Tool (Attride-Stirling).

A survey was carried out with members of the Association of Chartered Physiotherapists in Respiratory Care (ACPRC) (32 participants) to investigate how behaviour change in relation to self-management was understood and implemented in clinical practice from the perspective of Respiratory Physiotherapists. Data was analysed using the Theoretical Domains Framework (Atkins et al, 2017).

The focus group and survey data were then combined and analysed using behaviour change theory using the Behaviour Change Wheel (Michie et al, 2011) and the Capability, Opportunity and Motivation of Behaviour (COM-B) Model (Michie et al, 2011).

Findings
Findings from the focus groups included the global theme of the ‘Influence of behaviour on self-management’ followed by four organising themes. These included: ‘Motivation to exercise’, ‘Influence of education on self-management’, ‘Psychological impact of symptoms’ and ‘Perceived benefit and engagement in Pulmonary Rehabilitation’. Basic themes included a range of known barriers including: anxiety and depression, fear, motivation, blame, education, support networks, goal setting and exacerbations.

Survey findings shared some similarities to the focus group findings. Time, expertise and knowledge were noted as barriers from a service perspective. Whilst motivation, knowledge, education and support mechanisms were seen as both enablers and barriers to successful self-management from patient and Physiotherapist perspectives. Behaviour change techniques commonly employed included goal setting, health coaching, self-efficacy and motivational interviewing. The most frequently cited domains within the Theoretical Domains Framework included: knowledge, skills, social and professional role and identity, beliefs and capabilities and beliefs about consequences.

Using behaviour change theory and models the data from the focus groups and survey were combined to look more closely at behaviour change in self-management. The COM-B model was used to determine elements in relation to patients’ Capability. Physical aspects included: skills, tools, exacerbations and breathlessness, whilst psychological elements included knowledge, education and anxiety and depression. Aspects related to the Opportunity from a physical point of view included: time, transport and work-related barriers and from a social point of view included: socio-economic status and the expert patient role. From a Motivation perspective, reflective aspects included: goal setting, self-efficacy and empowerment and from an automatic point of view included: fear and anxiety and depression. The main intervention functions cited included: education, and training using skills and tools. There was some consensus on the definition of self-management as being patient-centred and individualised using empowerment. In contrast, there was some variation on the role of being educated verses educating and the purpose of self-management in achieving long-term commitment to managing their own condition.

Conclusion
The unique contribution from this thesis highlighted a conflict between the biomedical and psychosocial model of healthcare. A missing link was identified between the intentions and actions by Healthcare Professionals in supporting behaviour change in self-management compared to the needs of patients to be able to achieve behaviour change. The unique viewpoint of analysing the data from a Critical Realist perspective allowed for investigation of the underlying causal mechanisms associated with the ontological domains of the Real, the Actual and the Empirical. The COVID-19 pandemic has provided an opportunity to develop a workforce transformation to embed new philosophical thinking from a Critical Realist view on behaviour change in self-management.

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