Table 5.

Matrix of integrated results

TDF domain	Phase 1: qualitative study main factors	Phase 2: survey main factors	Barrier—✗/Enabler—✓
Social and professional role	It is largely seen as the practice nurse role, or staff undertaking COPD review The best time to refer a patient is when they are stable Most PHCPs believe in encouraging patients to attend	Not clearly PNs role, but PHCP doing annual review is most likely referrer Disagree Agree	PHCP undertaking annual review (not necessarily the PN)—✓ Not generalisable in quantitative data ✓
Knowledge	Generally a good basic knowledge Little detailed local programme knowledge Knowledge is largely gained from CPD/networking	Agree (generally higher in frequent referrers) Disagree (higher local knowledge in frequent referrers) Agree	Enabler—but room for improvement ✓ ✓
Environment	There is a lack of time in practice Referral is only considered during non-acute COPD focused consultations There is a lack of PR promotional material available in practices	Disagree Agreed (some infrequent referrers reported not to see patients with COPD) Agree	Not generalisable in the quantitative data ✗ ✗
Memory	On screen reminders are important Referral prompted when patients have symptoms that are worsening	Agree Disagree	✓ Not generalisable in the quantitative data
Optimism	Patients do not want PR/are not motivated PR providers do not offer a good service	Agree Some agreement more so with infrequent referrers	✗ ✗
Belief about consequences	PR is good for patient’s physical and psychological health PR may harm patients (psychologically) Pushing PR might harm my relationship Patients will not always attend and complete post referral	Agree Disagree Disagree General agreement	✓ Not generalisable in the quantitative data Not generalisable in the quantitative data ✗
Belief about capability	Talking to patients about PR is challenging Patients in work are unable to attend PR Transport is a barrier Not for patients with oxygen Not for patients who smoke Best suited to those who have frequent exacerbations	Some agreement more so with infrequent referrers Agree Agree (open question) Disagree Disagree Disagree	✗ ✗ ✗ Not generalisable in the quantitative data Not generalisable in the quantitative data Not generalisable in the quantitative data
Social influences	Lack of PR provider engagement and feedback to referrer Patients do not ask for PR	Agree Agree	✗ ✗
Skills	Referral to PR by PHCP is low Referral process is relatively easy	Agree Disagreement, particularly by infrequent referrers	✗ Likely barrier
Reinforcement	Financial reward increases referral rates Patients decline PR Financial reward increases practice awareness	Most do not think this would change behaviour Not captured explicitly Agree	Not generalisable in the quantitative data Likely barrier ✓
Goals	No set in-practice process to improve or review referral rates.	Agree	✗
Intentions	Referral acceptance takes time General desire to refer more patients	Not captured explicitly Not captured explicitly	Likely barrier Likely enabler
Emotion	PHCPs are fearful on behalf of patients Frustration with PR providers	Concern over access abilities (expressed in free text, may capture PHCP fear) Not captured explicitly	✗ ✗
Behavioural regulation	PHCPs do not know how many patients they have referred PHCPs have no planned intentions to change behaviour	Agree Largely agree, although some emerging interventions (free text)	✗ Likely barrier

✗Barrier and agreement with Phase 1 data.

✓Enabler and agreement with Phase 1 data.

COPD, chronic obstructive pulmonary disease; CPD, continuous practice development; PHCPs, primary healthcare practitioners; PN, practice nurse; PR, pulmonary rehabilitation.