Priority setting of healthcare provider barriers and facilitators to supporting patient physical activity in rheumatology: a nominal group technique study

Abstract

Objective

To determine the most important barriers, facilitators and resources identified by rheumatology healthcare providers (HCPs) to supporting physical activity (PA) among individuals with rheumatoid arthritis (RA).

Methods

Nominal group technique (NGT) sessions were conducted with rheumatology HCPs following a structured process of idea generation, discussion and independent rating. Determinants and resources were grouped into themes and mapped to the Behaviour Change Wheel.

Results

A total of 14 rheumatology HCPs participated in four NGT sessions. RA HCPs identified 14 facilitators and 14 barriers to PA promotion, along with 12 helpful resources and 13 additional resource needs. The most important facilitators were patient-centred PA discussions, reassurance around movement safety and delegating PA counselling to exercise professionals. Key barriers included limited time, patient information overload and ineffective handouts. Six overarching themes were emphasised after grouping and theoretical mapping: patient–provider conversations, interdisciplinary teamwork, counselling skills, monitoring and feedback, time and capacity and resource quality. The six categories of key resources were tailored programmes, educational handouts, referral tools, exercise professionals, online tools and professional development.

Conclusion

This study identified key barriers and facilitators influencing how rheumatology HCPs support PA among RA patients, highlighting the importance of tailored discussions, interdisciplinary teamwork, counselling skills and supportive resources. HCPs emphasised the need for high-quality, RA-specific resources such as allied health networks and RA-specific programmes. Theoretical mapping pinpointed targets within capability, opportunity and motivation to enhance PA promotion. Ongoing work is underway to codevelop evidence-based tools addressing these determinants to improve PA support for individuals with RA.

WHAT IS ALREADY KNOWN ON THIS TOPIC

• Physical activity (PA) is internationally recommended as an effective method for managing commonly associated symptoms and health-related risk factors of rheumatoid arthritis (RA).

• A key barrier to initiating and maintaining healthy levels of PA among individuals with RA is a lack of tailored advice and support from healthcare providers (HCPs).

• Research examining key determinants to PA promotion in rheumatology care is needed to develop effective tools and strategies to support rheumatology HCPs in promoting PA in clinical settings.

WHAT THIS STUDY ADDS

• Six key themes emerged from HCPs highlighting barriers and facilitators to promoting and supporting PA in rheumatology care. These included patient–provider conversations, interdisciplinary teamwork, counselling knowledge and skills, monitoring and feedback, available time and provider capacity and quality of resources.

• HCPs also identified six categories of helpful resources to enhance PA promotion in clinical practice, including tailored programmes, handouts, referral/prescription, exercise professionals, online resources and professional development opportunities.

• This study mapped key determinants of HCP-led PA support in rheumatology care to capability (eg, limited counselling skills), opportunity (eg, time constraints) and motivation (eg, consequences).

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

• Theoretical mapping used in this study pinpoints behavioural determinants as intervention targets, laying the groundwork for developing evidence-based tools to integrate PA promotion into routine RA care.

• For example, targeting barriers such as HCP time constraints and limited access to quality resources—both linked to opportunity—can support the inclusion of exercise professionals in multidisciplinary care teams and enhance connections to community-based PA programmes.

• These insights will inform the codevelopment of practical, evidence-informed resources and contribute to practice improvements aimed at supporting routine PA promotion in rheumatology care.

Introduction

Rheumatoid arthritis (RA) is a chronic inflammatory condition affecting approximately 1% of Canadians, leading to joint pain, fatigue, reduced functional ability and an increased risk of developing other conditions such as cardiovascular disease, osteoporosis and depression.1,4 Regular physical activity (PA) is internationally recommended as an effective way to counteract debilitating symptoms (eg, fatigue), improve overall health (eg, physical function, cardiorespiratory fitness, quality of life) and reduce cardiovascular disease risk.⁵ Despite these well-established benefits, PA levels among people with RA remain significantly lower than healthy adults.^{6 7} A key factor contributing to this gap is a lack of tailored PA advice and support from RA healthcare providers (HCPs, ie, rheumatologists, nurses and allied health), with one survey of 108 participants with inflammatory arthritis finding that less than half had received tailored PA guidance based on disease-specific guidelines for PA promotion.⁸

Rheumatology HCPs play a vital role in encouraging PA as their advice is highly valued by patients.⁹ However, many providers report low self-efficacy and discomfort in initiating PA discussions and providing specific exercise recommendations and often report feeling time-constrained by the need to prioritise medication management during clinical visits.10,12 These challenges are not unique to rheumatology settings, HCPs such as general practitioners have also cited time constraints, limited knowledge and a lack of specific training as barriers to integrating PA counselling into routine care.¹³ Behaviour change interventions designed to address these barriers among other HCPs such as general practitioners and cardiologists have focused on improving PA counselling skills by providing educational workshops,¹⁴ using motivational interviewing techniques¹⁵ and developing and implementing clinical decision support tools.¹⁶

While insights from these broader contexts provide valuable examples of PA behaviour change strategies, a deeper understanding of the key determinants to PA promotion specific to rheumatology care settings is required to develop effective interventions, policies and tools that support rheumatology HCPs in promoting PA. The application of behavioural science theories and frameworks is essential in allowing researchers to select effective, evidence-based strategies that address barriers and facilitators to change.¹⁷ The Behavior Change Wheel (BCW) is a comprehensive framework for designing interventions based on behaviour theory to understand and identify strategies for effective intervention development.¹⁷ The Theoretical Domains Framework (TDF) is often mapped onto the BCW as a core component, providing a structured way to break down and understand specific factors that influence a target behaviour. This pairing systematically links identified behavioural determinants (categorised within the BCW’s ‘capability’, ‘opportunity’ and ‘motivation’ informed by the TDF’s detailed psychological and social constructs) to appropriate intervention functions and broader policy categories.^{17 18}

Targeted interventions, policies and resources specifically designed for, and informed by, RA HCPs are urgently needed to facilitate efficient and effective PA discussions. Evidence-based interventions and policies can be used to leverage facilitators, mitigate barriers and simplify processes, ultimately aiming to promote regular and effective discussions about PA within rheumatology clinics. Codesign approaches—where rheumatology clinicians are involved in planning, designing and implementing resources—can increase the successful uptake and long-term sustainability of behaviour change strategies used in clinical practice.¹⁹ Input from rheumatology HCPs ensures that proposed solutions are practical, feasible within clinical settings, avoid duplication of existing strategies and addresses the specific needs of HCPs and their patients.

Therefore, the aims of this study were to (1) determine the most important barriers and facilitators for rheumatology care providers when discussing PA with RA patients and to highlight existing resource gaps, (2) use theoretical mapping based on behavioural science to identify evidence-based strategies for improving the frequency and effectiveness of these conversations. The findings from our study will be used to guide future interventions, policy and tools designed to promote routine patient–provider PA discussions in rheumatology care.

Methods

We used a nominal group technique (NGT) approach to understand rheumatology HCP key determinants to discussing PA with RA patients.²⁰ It is reported according to the Consolidated Criteria for Reporting Qualitative Research Checklist.²¹ The NGT study was embedded within a larger grant aimed at codeveloping patient and provider toolkits to support PA behaviour change in rheumatology. As such, additional meaningful engagement of patient partners and rheumatology HCPs is embedded both prior to and following the present priority setting phase.²²

A methodological overview is shown in figure 1, which indicates the four phases of the research. Briefly, phase 1 (blue) included the collection of informed consent and baseline demographic, phase 2 (yellow) covered the virtual NGT sessions, phase 3 (grey) involved consolidating and rating all ideas generated across NGT sessions and phase 4 (orange) concluded with analysis and mapping of findings (more details are in the Theoretical mapping section).

Figure 1. Methodological study overview.

Participants and recruitment

All RA HCPs (rheumatologists, doctors, nurses, social workers and physical and occupational therapists) with active clinical roles involved in the management of individuals with RA were eligible to participate. Recruitment involved convenience and snowball sampling, alongside purposive selection aimed at achieving representation across provinces, practice duration, gender and practice type and setting (eg, community and academic). Identified participants received an email with a study overview and a link to the electronic informed consent form. All participants provided informed consent before taking part in the study.

NGT protocol

An NGT priority-setting approach was selected to guide idea-sharing and rating, encouraging balanced participation and capturing diverse perspectives. NGT is known for amplifying quieter voices, promoting structured discussion and identifying actionable priorities.²³ Groups of 2–9 participants are recommended, with 2–5 sessions suggested to strengthen the external validity of consensus findings.^{20 23 24} Four 60–90 min NGT sessions were conducted with RA HCPs. Sessions were scheduled flexibly across various days to accommodate participants’ time zones across Canada. All sessions took place in November 2024.

A facilitation guide followed a standard three-step NGT process: (1) individual idea generation, (2) structured sharing and discussion to refine comprehensive lists and (3) independent rating to develop consensus.²² Our approach was adapted from prior NGT studies involving RA patients and scleroderma.²⁵ The guide was pilot tested and refined by the research team before the first session. Sessions were hosted via Zoom Workplace (Zoom Video Communications, 2024), and two experienced moderators facilitated each discussion. A step-by-step overview is provided in table 1. Two moderators from the research team with experience in discussion-based research facilitated each session. A step-by-step overview of the NGT process is provided in table 1.

Table 1. Step-by-step overview of NGT Process with HCPs.

Introductions and session overview (10–20 min)	Introductions and rapport-building between participants. Moderators explained study purpose and welcomed HCPs. HCPs shared experiences on supporting RA patients' physical activity.
Step 1: Brainstorming part 1: facilitators and helpful resources (15 min)	Guiding questions related to facilitators and helpful resources. Participants were asked to record or remember their thoughts (writing down of ideas). What successful approaches have you used to discuss and support your patients in becoming and staying physically active? What information, tools or resources do you have to support your patients in becoming and staying physically active? Ideas were shared, refined and discussed (structured sharing and discussion).
Step 2: Brainstorming part 2: barriers and resource needs (15 min)	Guiding questions related to barriers, resource needs and gaps. Participants were asked to record or remember their thoughts (writing down of ideas). What information, tools or resources would you want to have to better support your patients in becoming and staying physically active? What challenges do you face that make it difficult to support your patients in becoming and staying physically active? Ideas were shared, refined and discussed (structured sharing and discussion).
Conclusion (5–10 mins)	Moderators thanked participants and explained a list of barriers and facilitators would be emailed. Final opportunity for questions was provided.
Step 3: Independent rating of barriers and facilitators (10–15 min)	A Qualtrics survey with barriers and facilitators was emailed to participants for review and rating following the session. Ratings were averaged to identify top priorities among HCPs.

HCPs, healthcare providers; NGT, nominal group technique; RA, rheumatoid arthritis.

After the NGT sessions, the research team compiled and refined barriers, facilitators and resource needs into a consolidated master list, using consensus discussions to reduce redundancy prior to rating. This list was converted into a Qualtrics (Qualtrics, Provo, Utah) rating survey, which was reviewed before distribution. To minimise HCP time commitments during sessions, the survey was shared by email afterwards.

Data collection and analysis

Data relating to participant demographics, NGT sessions and theoretical mapping were collected and analysed. Participant data were deidentified to protect participant privacy and subsequently stored in a secure, encrypted and password-protected OneDrive account (Microsoft, Redmond, Washington).

Participant demographics

Demographic information including age, gender, race and ethnicity, provider type, years of practice, number of patients seen per week, practice setting, location (province of practice) and leisure-time activity levels was collected using an online survey. The survey was collected at baseline, directly after completing the informed consent. Activity levels were assessed by asking participants to report their weekly PA behaviours using the Godin Leisure-time Exercise Questionnaire (GLTEQ).²⁶ This questionnaire asks participants to report their usual weekly frequency of strenuous, moderate and mild/light PA in at least 15 min bouts. The GLTEQ has been validated in various populations, including university-educated healthy adults similar to those in our study, and has demonstrated the ability to distinguish between active and inactive individuals, with active individuals showing significantly higher maximal oxygen consumption, lower body fat percentages and greater fitness centre attendance.²⁶ Participant demographics and PA levels were summarised using descriptive statistics. Means and SD were calculated for normally distributed continuous variables. Medians and IQRs were calculated for non-normally distributed continuous variables. Frequencies and percentages were calculated for categorical variables. For PA levels, the GLTEQ leisure score index was calculated according to GLTEQ guidelines: strenuous bouts*9+moderate bouts*5+mild bouts*3. The leisure score index classifies participants as insufficiently active (less than 14), moderately active (14–23), or active (24 or greater).

NGT sessions

Data were recorded by the research team throughout all NGT phases, including idea generation, discussion and rating, using a standardised Microsoft Word note-taking template. Sessions were also audio recorded to ensure findings accurately reflected participant perspectives. After the sessions, each participant received a Qualtrics survey link and was asked to rate the personal importance of each facilitator, barrier and resource need on a 9-point Likert scale (1=‘not important’, 9=‘extremely important’). Ratings were summarised using descriptive statistics and ranked by mean importance. SD, median and IQR were calculated to assess the influence of extreme values. Following best practices for 9-point scales, rating frequencies were categorised as low (1–3), medium (4–6) and high (7–9). The top two tertiles of barriers, facilitators and resource needs (ie, those with the highest importance) were carried forward to the theoretical mapping stage.

Theoretical mapping

Following the main NGT analyses, mapping was completed by the lead author (ME) in collaboration with research team members (DCG, CB), with ongoing discussion to resolve discrepancies and reach consensus. Inductive thematic content analysis was used to group-related HCP barriers and facilitators to supporting patient PA in rheumatology care as well as important resources for healthcare teams.²⁷ The three authors (ME, DCG and CB) iteratively grouped related barriers and facilitators, as well as resource needs, into related themes. Theoretical mapping then categorised items into the BCW domains—capability, opportunity and motivation—and further mapped them onto the TDF.^{17 18} The mapping was led by a behavioural scientist (ME) based on the official BCW guide.¹⁷ Each of the identified TDF domains was linked to potential intervention functions and behaviour change techniques using the BCW and TDF frameworks. Finally, the team refined theme definitions and determined the most effective way to visually present the data using tables and figures.

Results

Fourteen HCPs participated across four NGT sessions lasting between 45 and 75 min. One session had six participants, 2 sessions had three participants and one final session had two participants.

Participant characteristics

Table 2 presents a summary of participant demographics and PA levels. HCPs were 45.8±10.4 years old, on average. Most participants were female (11/14, 78.6%). Eleven participants were white (11/14, 78.6%), and most were from Alberta (9/14, 64.3%). There were 11 rheumatologists, 3 of whom were formerly physiotherapists, 2 physiotherapists and 1 registered nurse. Years of experience varied from less than 3 to greater than 30, with majority of participants practising between 3–10 years (28.6%) and 11–20 years (35.7%). All participants were either moderately active (2/14, 14.3%) or active (12/14, 85.7%).

Table 2. Healthcare provider demographics and physical activity levels.

	Mean	SD
Age	45.8	10.4
Gender	N	%
Female	11	78.6
Male	3	21.4
Race/ethnicity	N	%
White/European	11	78.6
Indigenous (First Nations/Inuit/Metis)	1	7.1
Southeast Asian (eg, Chinese, Vietnamese, Filipino)	2	14.3
Provider type	N	%
Rheumatologist	8	57.1
Rheumatologist (former physiotherapist)	2	14.3
Physiotherapist	2	14.3
Paediatric rheumatologist (former physiotherapist)	1	7.1
Registered nurse	1	7.1
Years of practice	N	%
<3	2	14.3
3–10	4	28.6
11–20	5	35.7
21–30	0	0.0
>30	3	21.4
Number of RA patients per week	N	%
1–10	6	42.9
11–20	5	35.7
>20	3	21.4
Practice setting	N	%
Academic clinic	9	64.3
Community-based	2	14.3
Primary care	1	7.1
Public hospital	1	7.1
Multiple	1	7.1
Province	N	%
Alberta	9	64.3
Ontario	2	14.3
Nova Scotia	2	14.3
Newfoundland+Labrador	1	7.1
Physical activity, weekly frequency*	Mean	SD
Mild	2.1	2.0
Moderate	3.1	2.3
Strenuous	3.6	2.1
Godin Leisure Score Index26	N	%
Insufficiently active	0	0.0
Moderately active	2	14.3
Active	12	85.7

^*Frequency of exercise sessions lasting more than 15 min in a typical 7-day (1 week) period.

RA, rheumatoid arthritis.

Initial list of barriers and facilitators

In total, HCPs discussed 39 facilitators and 35 barriers to supporting RA patients’ PA across the sessions. After consolidation, the finalised determinant list contained 14 facilitators and 14 barriers. HCPs also discussed 12 helpful resources that they leverage as well as 13 resource needs to address. These 53 items were included in the rating survey.

Rating of most important determinants to support patient PA

A brief description of each facilitator (strategy and helpful resource), barrier and resource need is provided in tables3 4, alongside the respective mean importance rating.

Table 3. Healthcare provider ratings of facilitators to support patient physical activity.

	Mean	SD	Median	Tertile
Facilitators (strategies)
Focusing on what is important to patients when discussing physical activity benefits with them (symptom management, physical health and function, mental health).	7.64	1.15	7.50	3
Give patients reassurance that movement is safe and valuable	7.50	1.51	8.00	3
Hand over physical activity discussion to an exercise professional or other allied healthcare provider (interdisciplinary model)	7.43	1.70	8.00	3
Provide positive feedback on progress (affirm actions, celebrate small improvements)	7.36	1.08	8.00	3
Simplify movement to make it accessible (all movement counts, find simple ways to move)	7.07	1.44	7.00	3
Complete physical activity screening to find out where patients are at (baseline check-in to guide further discussions)	6.86	2.07	7.00	2
Set aside time (whatever possible) to approach the topic and find the right moment to discuss physical activity (eg, moments of opportunity when patients are doing well)	6.71	1.94	7.00	2
Acknowledge and normalise common physical activity barriers (pain, time, cost, etc.)	6.64	1.22	7.00	2
Refer patients to physiotherapy	6.57	1.50	6.50	2
Discuss and leverage incentives (social benefit, prescription to get active to remove cost/access barriers)	6.43	1.99	7.00	1
Refer patients to tailored exercise programmes (eg, Good Life Living with osteoarthritis in Denmark (GLA:D)	6.29	2.02	7.00	1
Collaborate with available community partners (recreation centres, university kinesiology department, etc.)	6.07	2.02	6.50	1
Set a physical activity goal in a shared decision with the patient (revise at each visit)	6.00	1.84	6.00	1
Facilitators (resources)
Physical activity counselling (led by exercise professional or other allied healthcare provider)	7.21	1.89	8.00	3
Community support groups that include movement sessions	7.21	1.72	7.00	3
List of local exercise facilities, especially those that are free/low cost	7.00	1.30	7.00	3
Physiotherapy/occupational therapy prescription	6.79	2.08	7.00	3
Tailored physical activity programmes (eg, Good Life Living with osteoarthritis in Denmark (GLA:D)	6.64	2.10	7.00	2
Physical activity handouts/workbooks (print resources)	6.14	1.79	6.00	2
‘Prescription to get active’ (physical activity prescription)	5.86	1.70	5.50	2
Specific exercises sent via electronic health record (after visit summary: lower back pain, rotator cuff, etc.)	5.64	2.21	6.00	2
Toolkits that include basic activities around the house	5.64	2.41	6.50	2
Website portals (Exercise is Medicine*, vs Arthritis†, Power over pain‡, etc.)	5.57	2.31	6.00	1
Mobile technology: wearable devices or physical activity apps	5.43	2.38	6.00	1
Physical activity videos (trusted sources)	5.36	2.02	5.50	1

^*Exercise is Medicine: https://www.exerciseismedicine.org/.

^†Versus Arthritis: https://versusarthritis.org/.

^‡Power over Pain: https://poweroverpain.ca/.

Table 4. Healthcare provider ratings of barriers and resource needs to support patient physical activity.

	Mean	SD	Median	Tertile
Barriers
Lack of time (finding time to discuss physical activity while dealing with other priorities in 15–20 min appointment)	8.00	1.41	8.50	3
Patient fatigue due to information overload (disease, medications, bloodwork, and then physical activity)	7.29	1.49	8.00	3
Handouts alone are not good enough to change behaviour	7.21	1.48	8.00	3
Lack of knowledge about available resources (constantly changing availability)/limited resources available	6.86	1.51	7.00	3
Lack of support from allied healthcare providers (physiotherapists, occupational therapists, exercise professionals, social work, other)	6.64	2.98	8.00	3
Community exercise professionals (kinesiologists, physiotherapists, trainers) lack RA-specific knowledge to tailor physical activity appropriately	6.64	1.91	7.00	3
Lack of physical activity knowledge/expertise/skills (doctors not as trained/qualified to provide physical activity advice)	6.57	2.59	7.00	2
Inability to track what patients actually do after advice provided in clinic	6.50	1.83	7.00	2
Unsure how to address significant patient physical activity barriers (eg, access to exercise facilities, costs, motivation)	6.00	2.42	7.00	2
Questionable resource quality (evidence-base, regular updates)	5.86	1.61	6.00	1
Difficult to manage patient expectations (responding to setbacks without getting discouraged)	5.50	2.21	5.50	1
Perceived lack of motivation or value from patients (physical activity not perceived as important)	5.36	2.53	6.00	1
Physical activity may not be appropriate for all patients: some are too unwell to approach topic	4.93	2.23	5.00	1
Frustration about lack of teamwork/quality when collaborating with allied health professionals	4.71	2.55	5.00	1
Resource needs
Allied health professionals integrated into the clinic: physiotherapy, occupational therapy, social work, exercise professional, nutrition (with scheduled visits)	8.00	2.22	9.00	3
Vetted lists of safe, high-quality physical activity resources (including what to look for in an exercise programme or professional)	7.71	1.49	8.00	3
Interactive group information sessions on movement/nutrition for patients with rheumatologic conditions (led by allied healthcare provider)	7.57	2.06	8.00	3
Expanded regional arthritis-specific physical activity programmes	7.50	1.16	7.50	3
Tailored, fun and accessible physical activity resources for different groups and preferences (culture, age, gender, life course, abilities, etc.)	7.21	1.67	7.50	3
Qualified exercise professionals with RA-specific training	7.14	1.67	8.00	2
Online education modules that we can refer patients to	7.00	1.88	7.50	2
Group information/training session for rheumatology care providers (tips for supporting your patients to move more)	6.64	1.60	6.50	2
Visual overview handout on ‘Why?’ (benefits of moving more for your RA, function, etc.)	6.43	1.79	6.50	2
YouTube videos for RA-specific exercises	6.43	1.91	6.50	2
Simplified general ‘movement’ type resources (getting started)	6.14	2.25	6.50	1
Tools to simplify goal-setting and self-monitoring of physical activity	5.86	1.75	5.50	1
Improved leveraging of electronic health records for physical activity support (automatic reminders to providers, tailored resources sent to patients)	5.14	2.25	6.00	1

RA, rheumatoid arthritis.

For facilitators, mean ratings (±SD) ranged from 5.3±2.7 to 7.6±1.2 out of 9. The three most important facilitators were (1) focusing on what is important to patients when discussing PA benefits with them, (2) giving patients permission to move their body by reassuring them about safety and (3) delegating PA discussions to exercise professionals or allied healthcare providers.

Mean importance ratings (±SD) for the 14 barriers ranged from 4.7±2.6 to 8.0±1.4. The three most important barriers were (1) lack of time to discuss PA, (2) perceived patient fatigue due to information overload and (3) ineffectiveness of handouts alone to change behaviour. Key helpful resources included PA counselling by an exercise professional, community support groups with PA sessions and a list of appropriate and accessible local exercise facilities. Meanwhile, important resource needs were more allied health professionals integrated into clinics, verified and up-to-date lists of safe, high-quality PA resources and interactive group information sessions on movement and related self-care topics. The top two-thirds of facilitators and barriers to supporting patient PA were included for theoretical mapping.

Theoretical mapping of determinants for supporting patient PA

The theoretical map of key facilitators and barriers to supporting patient PA, as discussed by various rheumatology HCPs, is shown in table 5. Thematic grouping of determinants resulted in six overarching themes: patient-provider conversation (five facilitators, one barrier), interdisciplinary teamwork (two facilitators, two barriers), counselling knowledge and skills (three barriers), monitoring and feedback (two facilitators, one barrier), available time and provider capacity (one facilitator, one barrier) and quality of resources (two barriers).

Table 5. Theoretical mapping of key healthcare provider barriers and facilitators to supporting.

Category	Description	COM-B factor	Primary TDF domain	Secondary TDF domain
Patient–provider conversation	Discuss physical activity benefits with patient (symptom management, physical health and function, mental health), focus on what’s important to patients	Motivation	Intentions	Beliefs about capabilities, beliefs about consequences
	Give patients reassurance that movement is safe and valuable	Capability	Behavioural regulation
	Simplify movement to make it accessible (all movement counts, find simple ways to move)
	Complete physical activity screening to find out where patients are at (baseline check-in to guide further discussions)
	Acknowledge and normalise common physical activity barriers (pain, time, cost, etc.)
	Patient fatigue due to information overload (disease, medications, bloodwork and then physical activity)
Interdisciplinary teamwork	Hand over physical activity discussion to an exercise professional or other allied healthcare provider (interdisciplinary model)	Opportunity	Environmental context/resources	Social Influences
	Refer patients to physiotherapy	Motivation	Social/professional role and identity
	Lack of support from allied healthcare providers (physiotherapists, occupational therapy, exercise professionals, social work, other)
	Community exercise professionals (kinesiologists, physiotherapists, trainers) lack RA-specific knowledge to tailor physical activity appropriately
Counselling knowledge and skills	Lack of knowledge about available resources, which change constantly	Capability	Knowledge	Skills
	Lack of physical activity knowledge/expertise/skills (doctors not as trained/qualified to provide physical activity advice)	Motivation	Beliefs about capabilities
	Unsure how to address significant patient physical activity barriers (eg, access to exercise facilities, costs, motivation)
Monitoring and feedback	Complete physical activity screening to find out where patients are at (baseline check-in to guide further discussions)	Motivation	Beliefs about consequences
	Provide positive feedback on progress (affirm actions, celebrate small improvements)	Motivation	Optimism/pessimism
	Inability to track what patients actually do after providing advice
Available time and provider capacity	Set aside time (whatever possible) to approach the topic and find the right moment to discuss physical activity (eg, moments of opportunity when patients are doing well)	Motivation	Intentions	Social/professional role and identity
	Lack of time (finding time to discuss physical activity while dealing with other priorities in 15–20 min appointment)	Opportunity	Environmental context/resources
Quality of resources	Limited high-quality resources available	Opportunity	Environmental context/resources
	Handouts alone are not good enough to change behaviour	Motivation	Optimism/pessimism	Beliefs about consequences

Green = facilitators, red = barriers.

COM-B, Capability, Opportunity, Motivation—Behaviour; TDF, Theoretical Domains Framework.

After theoretical mapping was completed, patient–provider conversation related to HCP motivation, including their intentions and beliefs about capabilities as well as consequences, and capability, with an emphasis on behavioural regulation (ie, managing or changing actions or habits). Interdisciplinary teamwork mapped to opportunity, specifically the ‘environmental context and resources’ domain, and secondarily to motivation, specifically the ‘social or professional role and identity’ domain. Counselling knowledge and skills mapped to capability, with relevant TDF domains being ‘knowledge’ and ‘skills’ as well as motivation, impacted by provider ‘beliefs about capabilities’. Monitoring and feedback mapped to motivation, including the domains ‘beliefs about consequences’ and ‘optimism’. Available time and provider capacity related to opportunity, especially ‘environmental context and resources’ as well as motivation, including provider ‘intentions’ and ‘social or professional role and identity’. Finally, quality of resources was linked to opportunity, the ‘environmental context and resources’, and motivation, with both ‘optimism’ and ‘beliefs about consequences’ being relevant factors.

Thematic grouping of important resources to support patient PA

After grouping the most important and needed resources for HCPs, six categories of resources were highlighted by the data (table 6). These include tailored programmes, handouts, referral or prescription tools, exercise professionals, online resources and professional development opportunities. More information for each category, including examples, is detailed in table 6.

Table 6. Themes of important resources for healthcare teams to support patient physical.

Category	Description
Tailored programmes	Physical activity counselling (led by exercise professional or other allied healthcare provider) Community support groups that include movement sessions Tailored physical activity programmes (eg, Good Life Living with osteoarthritis in Denmark (GLA:D)
	Interactive group information sessions on movement/nutrition for patients with rheumatologic conditions (led by allied healthcare provider)
	Expanded regional arthritis-specific physical activity programmes
	Tailored, fun and accessible physical activity resources for different groups and preferences (culture, age, gender, life course, abilities, etc.)
Handouts	List of local exercise facilities, especially those that are free/low cost
	Physical activity handouts/workbooks (print handouts)
	Toolkits that include basic activities around the house
	Vetted lists of safe, high-quality physical activity resources (including what to look for in an exercise programme or professional)
	Visual overview handout on ‘Why?’ (benefits of moving more for your RA, function, etc.)
Referral/prescription	Physiotherapy/occupational therapy prescription ‘Prescription to get active’ (physical activity prescription) Specific exercises sent via electronic health record (after visit summary: lower back pain, rotator cuff, etc.)
Exercise professionals	Physical activity counselling (led by exercise professional or other allied healthcare provider)
	Allied health professionals integrated into the clinic: physiotherapy, occupational therapy, social work, exercise professional, nutrition (with scheduled visits)
	Qualified exercise professionals with RA-specific training
Online resources	Online education modules that we can refer patients to
	Online videos for RA-specific exercises
Professional development	Group information/training session for rheumatology care providers (tips for supporting your patients to move more)

Green = facilitators. Red = barriers.

RA, rheumatoid arthritis.

Discussion

Summary of key findings

In this study, we sought to identify the most important determinants of HCP-led PA support in rheumatology care, using behavioural science theories and frameworks to understand these determinants and inform evidence-based solutions. HCPs emphasised the importance of tailored patient–provider conversations, interdisciplinary teamwork and ongoing monitoring to support PA among individuals with RA. Notable challenges included time and resource limitations, PA counselling skills and knowledge, and accessing quality PA resources. The frequency and quality of PA support provided by rheumatology HCPs may be improved by targeting their capability, opportunity and motivation.

Capability

An ever-present barrier to HCP-led PA support, both in rheumatology and other care contexts, is a lack of knowledge and skills to counsel patients towards meaningful increases in PA.^{13 28} While there is a definite need to address this gap through training modules on PA counselling for rheumatology HCPs, an underappreciated challenge to capability is that of behavioural regulation, a key part of building habits. Theoretical mapping highlighted this TDF domain during our study. HCPs often have highly optimised habits in their busy rheumatology clinics. These need to be understood and targeted to increase PA counselling behaviours, even after the right training modules are provided. In prior work among primary care providers, even when competence for PA counselling was high, half of HCPs self-reported low capability to change patient PA behaviours.²⁹ Interventions that focus on enablement, helping HCPs create action plans for integrating PA discussions into their workflow, could be tested to drive behaviour change. Furthermore, resources that guide HCPs through rapid, effective PA discussions may be beneficial.

Opportunity

Tailored patient-provider PA discussions represent a key strategy to encouraging PA behaviour change in rheumatology. However, lack of time and limited interdisciplinary teamwork with exercise professionals and other allied healthcare providers limit the opportunities for such discussions. Our findings echo previous studies with primary care providers and rheumatology patients, emphasising the importance of time-efficient solutions to PA promotion.^{9 30} A proven, cost-effective strategy for increasing PA levels among individuals with chronic conditions is the integration of exercise professionals into interdisciplinary care teams.³¹ This has been demonstrated in cardiac rehabilitation and other conditions.^{32 33} Some success stories of interdisciplinary rheumatology care exist in Canada, yet many care contexts lack leadership, buy-in or available upfront resources to implement such changes. To overcome these resource limitations, improving collaboration with exercise professionals and resources outside of rheumatology clinics, such as regional PA promotion organisations and community programmes, is a promising approach. Community exercise professionals may require additional training to improve their knowledge of RA and understanding of how to tailor PA accordingly. A perceived lack of RA-specific knowledge, as indicated by our participants, has also been reported by other rheumatology HCPs and people with RA.^{22 28} Our work echoes prior research emphasising the need for efficient referral pathways for connecting RA patients to available PA resources as well as the development of more RA-specific PA resources.^{34 35} To address time restrictions, resources exist to guide quick PA conversations in chronic disease care. For example, the step-by-step conversation guide by Reid et al provides options for 1 min, 5 min or longer PA discussions with inflammatory rheumatic diseases.³⁶

Motivation

Despite the definite relevance of capability and opportunity towards PA counselling behaviours among rheumatology HCPs, most determinants discussed in our study and previous research have a motivational component.^{13 37} Motivation can be impacted, both positively and negatively, by beliefs about capabilities (ie, confidence to discuss PA), beliefs about consequences and optimism (ie, that PA counselling will change behaviour leading to health benefits), perspectives on professional role and identity (ie, PA counselling is part of my role) and intentions (ie, conscious decision to prioritise PA counselling). Our findings are aligned with prior work in rheumatology and primary care settings, where HCP beliefs about the value of PA, as well as the effectiveness of PA counselling, played a role in decisions to discuss PA with patients.^{13 37} Addressing capability and opportunity, through better training and resources for PA counselling, may also improve beliefs about capabilities and consequences.³⁸ Many rheumatology HCPs have concerns about potential joint damage caused by PA and overwhelming patient barriers, representing key topics for future training.²⁸ However, motivation-specific interventions such as persuasion, modelling and incentivisation may be needed to comprehensively address motivation. Top down, from healthcare leadership, and bottom up, from patient advocates, persuasion may improve positive attitudes towards the value of PA counselling and the HCP role in providing support. Patient advocacy is needed to address a key barrier to HCP PA promotion, the perceived lack of patient interest in PA.³⁹ In addition, pairing residents with experienced HCP role models that demonstrate PA counselling habits during their training can increase optimism and change perspectives.⁴⁰ Finally, financial incentives, such as billing codes for PA counselling, may address negative attitudes due to lack of reimbursement.¹³ Reimbursement was not discussed by our HCPs, which speaks to their intrinsic motivation for PA promotion. HCP motivation to discuss PA with their patients appears closely linked with their own personal PA habits.⁴⁰ Therefore, effective interventions to increase HCP PA levels may also lead to positive effects for patients.

Strengths, limitations and future research

The unique user-centred research codesign, with HCPs leading NGT discussions, and structured priority setting approach, are strengths of the present work.¹⁹ This methodology allowed us to amplify quieter voices and reduce the potential impact of dominant individuals in group discussions. Furthermore, the combination of a rating survey and theoretical mapping led to a deeper understanding of the most important behavioural determinants for PA counselling in rheumatology and strategies for targeting them in future interventions. However, mapping results should be interpreted with caution as there is no perfect formula for linking determinants to the TDF. The rating survey was completed by all participants, contrary to significant survey engagement challenges common with other priority setting methods (eg, Delphi⁴¹), whereas broad representation across many Canadian regions enhances generalisability, it may have caused us to overlook certain context-specific nuances. For example, baseline data on PA promotion intentions and behaviours, which may impact perceptions of barriers and facilitators, were not collected. More interviews are needed to design site-specific interventions and implementation plans. Due to the use of convenience and snowball sampling, participants were largely white doctors from academic clinics who were physically active themselves. Personal experience and PA history likely impacted their responses, as healthcare providers who are physically active themselves have been shown to be more likely to promote PA to their patients.⁴⁰ Our sample was slightly younger and had a higher percentage of female participants as compared with a national survey of 183 practising rheumatologists in Canada.⁴² Therefore, our findings may not be generalisable to all rheumatology HCPs. Greater efforts are needed to include under-represented perspectives in future work. This includes non-white and community-based doctors, other HCP types and those who are less active themselves. Given the lack of capacity and incentives for HCPs to participate in research, capturing these perspectives is challenging. Brief surveys or discussions in rheumatology rounds may be useful to invite broader input. Important next steps for this research include focusing on better understanding barriers and facilitators to PA support in diverse care settings (eg, community clinics, telehealth) and codeveloping evidence-based interventions that increase PA promotion across rheumatology.

Conclusion

This study represents a key step towards better understanding and strategically addressing the determinants of PA promotion by rheumatology HCPs. Findings emphasised notable barriers and facilitators related to tailored PA discussions, interdisciplinary teamwork, counselling skills and confidence and supportive resources. Furthermore, the value of high-quality resources, such as allied health networks and RA-specific programmes, was highlighted. Theoretical mapping identified potential intervention targets related to capability, opportunity and motivation for PA promotion. Work is now underway to codevelop evidence-based tools that target these behavioural determinants and ensure all individuals with RA receive PA support from their care team.

Data availability statement

Data are available upon reasonable request.