Table 1.

Barriers to sexual counselling delivery, COM-B components, selected intervention functions, selected BCTs and BCT translation within the intervention

Barriers identified (source)	COM-B component	Selected intervention functions	Selected behaviour change techniques	Translation of behaviour change techniques within the intervention
Lack of knowledge and guidelines/information [23, 32] Low awareness among staff of sexual problems and cardiovascular disease [23]	Psychological Capability	Education	5.1 Information about health consequences	Provide information on clinical guidance about returning to sexual activity Provide information on improved health consequences for patients who receive sexual counselling
			5.6 Information about emotional consequences	Provide information on improved QOL/emotion for patients who receive sexual counselling
			6.3 Information about other’s approval	Discuss best practice guidelines developed by experts recommending sexual counselling
Lack of training in the provision of sexual counselling [23]	Psychological Capability	Training	4.1 Instruction on how to perform a behaviour	Provide manual and checklist of how to deliver group session Provide step-by-step guidance on how to address sexual concerns if raised
			6.1 Demonstration of behaviour	Show videos clips of good examples of HCPs interacting with patients who raise sexual concerns
			8.1 Behavioural practice/rehearsal	Role play exercises of interacting patients who raise sexual concerns
Perceptions among staff that the provision of sexual counselling to female patients is more difficult [23, 32]	Social opportunity	Enablement	1.2 Problem solving	Work with HCPs to identify potential problems related to gender and means to overcome barriers
			13.2 Framing/reframing	Suggest that provision of sexual counselling to women is particularly important given greater difficulties for women in discussing these issues
			15.1 Verbal persuasion about capability	Provide positive feedback in relation to role play performance and link with ability to provide sexual counselling in real-life settings
		Modelling	6.1 Demonstration of the behaviour	Show video clips of good communication around sexual problems with women
Perceptions among staff that issues related to patient culture, religion and ethnicity can make sexual counselling more difficult [23, 32]	Social opportunity	Enablement	1.2 Problem solving	Work with HCPs to identify potential problems related to culture, ethnicity and religion and means to overcome barriers
			13.2 Framing/reframing	Suggest that provision of sexual counselling to all is particularly important given greater cultural, religious and ethnic diversity
		Modelling	6.1 Demonstration of the behaviour	Show video clips of good communication around sexual problems with people from different ethnic groups
A sense of embarrassment and discomfort with sexual matters among staff, exacerbated by the older age of many patients [32] Staff members’ fear of offending patients should they broach the topic of sex and sexuality [32]	Automatic motivation	Modelling	6.1 Demonstration of the behaviour	Show video clips of interactions with patients that minimises potential offence and embarrassment
		Persuasion	5.1 Information about emotional consequences	Provide info on improved health outcomes for all patients
			6.3 Information about others’ approval	Provide information on patient’s expressed need for sexual counselling
			13.2 Framing/reframing	Reframe discussing sexual issues as meeting patients’ needs rather than causing offence
The perception among staff that patients do not expect staff to ask about sex [23] The perception among staff that giving permission is not a staff responsibility [23]	Reflective motivation	Education	6.3 Information about other’s approval	Give examples from the CHARMS baseline study showing how cardiac patients wanted and needed their healthcare providers to ask them about sex.
		Persuasion	6.2 Social comparisons	Show how sexual counselling is already part of routine cardiac rehabilitation in some centres in Ireland, and how it is integrated with rehabilitation in other countries
			9.1 Credible source	Provide information on the guidelines on sexual counselling during cardiac rehabilitation from the ESC and the AHA
Low confidence (among staff in the area of sexual counselling) [23]	Reflective motivation	Persuasion	15.1 Verbal persuasion about capability	The CHARMS educator will provide verbal support and reassurance throughout the training session, telling the staff members that they can successfully provide sexual counselling to their patients.
		Modelling	6.1 Demonstration of the behaviour	Show video clips depicting a cardiac rehabilitation staff member providing sexual counselling in a confident, assured manner.
Perceptions about the relationships between gender and age and sexuality [23, 32]	Reflective motivation	Persuasion	5.1 Information about health consequences	Provide info on improved health outcomes for all patients
			5.2 Salience of consequences	Provide case studies of positive consequences of providing sexual counselling including patients who vary by gender and age
			5.6 Information about emotional consequences	Provide info on improved quality of life and emotional outcomes for all patients
			6.3 Information about others’ approval	Provide information on patients’ expressed need for sexual counselling including patients who vary by gender and age
			9.1 Credible source	Ensure credibility of CHARMS educator and include expert video clips on benefits for all patients
			13.2 Framing/reframing	Reframe discussing sexual issues as meeting patients’ needs regardless of gender or age
Staff perceptions of patients’ lack of readiness and awareness with regard to sexual issues [23]	Reflective motivation	Persuasion	6.3 Information about others’ approval	Provide information on patients’ awareness of sexual issues and expressed need for sexual counselling during cardiac rehabilitation