Table 1.
Quotes extracted from FPs discussion groups by theoretical domains framework determinant dimensions.
| TDF dimension | Extracted quotes |
|---|---|
| Knowledge | “When you called me, what struck me was that I don't see so many people who should not take statins and are taking them.” (K_Q1) |
| “Then also, the issue of the reliability of the guidelines is an issue... the sensitivity and specificity you have when making a decision... the issue of cholesterol is quite controversial.” (K_Q2) | |
| “Cholesterol levels have been very variable, and we didn't know if it was necessary to treat this in primary or secondary prevention, but then it became clear that it was in secondary, not in primary, that diabetics are in secondary, and if they're not... there we've also had a bit of trouble and so that could also be the cause of this prescription” (K_Q3) | |
| “I think that we have to be clear about that at least, that there's no evidence for giving statins, unless there's a family history, yes.” (K_Q4) | |
| “We are seeing that there are other added risk factors, there are diseases that we are seeing that have a greater risk of having that disease, rheumatism for example, but some other things aren't. In the analysis that you have made of Osakidetza, this might be there or not, but you probably haven't been able to see if they have a family history of sudden death, you cannot see if in addition to this they have other diseases that have to do with greater risk, which are being seen today. We don't see many of these.”(K_Q5) | |
| Skills | “..For us it is also easier to prescribe a pill… It's simple, I ask you to take a test in two months, and ask ‘Is everything okay? Does anything hurt? See you next year’ and, that's it, it was a test and two appointments.” (Sk_Q1) |
| “We have a training deficit in terms of the prescription of physical exercise and the prescription of nutrition in general and if you have some training it is because you have asked for it, because you have read about it, because you have shown interest. I believe that the way we are working, it is very complicated in the appointment with the patient, with the time we have and all the things we have to do…” (Sk_Q2) | |
| Beliefs about capabilities | “It is much harder to change the habits of someone who comes to have their cholesterol tested if they are about 40 or 45, with settled habits that are difficult to change… that's harder than, ‘Give me a pill and I am going to do it quickly’, and I have peace of mind.” (Cap_Q1) |
| “Walking progressively without getting tired, that works for everyone. I am not ready to prescribe physical activity. I think we can, but it is not effective.” (Cap_Q2) | |
| “This age group is people who are working and do not come to consult you except when they are sick for some reason, so they often pass under the radar. You ask them for a test, and their cholesterol is skyrocketing, but you don't get them to come to a consultation to see where they are failing, to be able to treat changes in habits... it is difficult to make them come to the health center, and it is also difficult to get them to make the changes... I think that there is a lot we don't see.” (Cap_Q3) | |
| Beliefs about | “And the decision is always going to be, just in case, I'm going to give it to them. And then you also defend yourself just in case.” (Con_Q1) |
| consequences | “Also, in the real world, statins are a spectacular, very effective drug. I have 270 cholesterol, I go on a diet or exercise and I get down to 240 and that's that. However, if I take the pill, after 3 months I am at 200” (Con_Q2) |
| “On the one hand we have the problem on both sides, we who find it more work and have a reward in the medium to long term in terms of results, and on the other hand what the user wants is immediacy now. They've come to ask us to solve it now.” (Con_Q3) | |
| “Patients also hear that statins are bad, that they can cause diabetes and brain hemorrhages... some stop taking them because they have heard that it can cause some problems, or there have been people who for muscular reasons have had to stop taking them and take others... there was one statin that came out and they had to withdraw it from the market... all of these are little things... but, well…” (Con_Q4) | |
| Motivation, goals, intent | “My experience is that maybe you have been saying to the patient for 2 or 3 years, ‘You have to take exercise, go for a walk’… and they always look for an excuse, ‘I can’t because of my work…', so in the end you say, ‘Well, leave it then’ and you give up.” (M_Q1) |
| “In the end it depends on the conviction that you have, if you are more convinced, you will dedicate more time. Personal conviction and what you want.”(M_Q2) | |
| Memory, attention, decision making | “We doctors are inert by definition. Clinical and therapeutic inertia is part of our makeup. We are very inert, whether to prescribe or to stop prescribing.”(MAD_Q1) |
| “Often, when you are not sure, the most normal thing that we doctors learn is to see something and prescribe, as that it is the fastest thing we have…. so we don't have to explain… it's easier to give medicine than to explain.” (MAD_Q2) | |
| “You are seeing patient 141, you are already tired, and someone has made an appointment for you to give them statins, they tell you that if something happens to them you will be responsible... And on top of it all, at that time of day you have low blood sugar... I ask you how you would manage that situation.” (MAD_Q3) | |
| “...the matter of the asterisk, and what happens when we see one... just today someone came to me with cardiovascular risk of 3 or 4, and had an LDL that was almost 190. This was a young woman of 40, with low cardiovascular risk, and she asked me if she had to take something for it.” (MAD_Q4) | |
| “And one thing, they should take away the asterisks, as we spend a lot of time explaining asterisks when we shouldn't have to.” (MAD_Q5) | |
| Environmental context, resources, | “Sometimes, most of the time, we don't have enough time, and the time factor is important for everyone I think, to tell them, to try to convince them.” (E_Q1) |
| constraints | “...I think that the pressure of attending patients may have too much influence on the matter of prescription.” (E_Q2) |
| “The Regicor does not mean you stop being a doctor, you have to continue being a doctor, just like we use the stethoscope as a tool. And the problem of the risk scale is good for the population, it is very good for population risks, but not for individuals, they weren't designed for that.” (E_Q3) | |
| “Well, that allows me to put if the patient is in primary or secondary prevention, if they have anxiety or not, are stressed or not... that allows me to modulate those risk modifiers, and gives me peace of mind in both senses. This patient doesn't need statins, I'm sure, and that one does need statins, certainly.” (E_Q4) | |
| “My nurse does it very well. I am very lucky, she is a highly trained woman who does it very well. So I delegate some things to her. But unfortunately, nowadays she is not always there, and not all nurses are trained...” (E_Q5) | |
| “… But it has to be at another level, multidisciplinary, health policies, health policies, lifestyle, which do not necessarily have to be based at the health center. It should also be involved but should not be the greatest weight and we should invest more in health policies especially in these types of people, the population base with least risk but who in the end are the ones that we can really prevent getting ill.” (E_Q6) | |
| “This age group includes people who are working and do not come to consult you except when they are sick for some reason, so they often pass under the radar. You ask them for a test, and their cholesterol is skyrocketing, but you don't attract them to a consultation to see where they are failing, to be able to treat changes in habits. That is the problem that I think we have in this age group. With older people who come to the health center more often, it's much easier. But with people who are at work... it is difficult to make them come to the health center, and it is also difficult to get them to make the changes... I think that there is a lot we don't see.” (E_Q7) | |
| “It is very difficult to get hold of them and to continue to call them in to make them get tests, like cholesterol, as they don't think much about prevention, because nothing hurts, and on top of that you restrict them a little, and in their life it is difficult for them to make those changes of habits so they don't come.” (E_Q8) | |
| Social and professional role and | “I've had the experience of stopping a patient's statins, and the endocrinologist asked them what the family practitioner thought they were doing, taking them off statins... and then in the end the endocrinologist or the cardiologist put them back on them.” (Rol_Q1) |
| identity | “You see that a patient who has been to the... endocrinologist or... a patient who is seen in oncology, then comes to us in a state because they tell them that the doctor has to lower their cholesterol. These colleagues have a completely different view from ours, that this is a disease, and it can be important, except for very high numbers, which is a separate issue. The cardiologist who sees patients every day with heart attacks and things like that is much more likely to prescribe statins than we are, who see that much less.” (Rol_Q2) |
| “This work is a bit beyond our usual work, but it should be a bit, it should direct us to giving a good prescription for physical education, where we can do this, or where there can be a good health provider who works in this way.” (Rol_Q3) | |
| Social influences | “Cholesterol doesn't hurt, but it is so well-known that people are terribly afraid of it. On the other hand, they are not afraid of weighing 100 kilos, or smoking, or not exercising, but cholesterol is something objective… ”(SI_Q1) |
| 11Maybe the message of the media has a lot of influence, maybe we should try to change it, so that people become more aware of what cardiovascular risk means, as they're not aware. I think that's where we spend most time, explaining it to them.” (SI_Q2) | |
| “I believe that, on this issue, unlike other health issues, people come with a very preconceived idea, because there is pressure. In fact, when people do some tests, the first thing they ask you when they come for the results, is how high their cholesterol is.” (SI_Q3) | |
| “But I am referring to the advertising in which exercise, healthy food is being promoted more… that is what needs to be promoted. In the past, people didn't know much about exercise, but now they are a little more aware. Another thing is to get them to do it on a regular basis. That is what is difficult for the patients.” (SI_Q4) | |
| “For the patient, when you explain these dietary hygiene measures, it's like you aren't telling them anything... ‘What did the doctor tell you? Nothing, the usual...’ So it has little weight and little value for them, it's like not telling them anything. However, if you give them a pill and send them to have tests, that's different.” (SI_Q5) | |
| “Sorry, I have to go now. I signed up for a congress to prescribe exercise, and they didn't accept me. I was amazed. The reply from the person in the department where I applied was: “That is not a primary medicine matter.” I was amazed. To cap it all, I was the first at that time.” (SI_Q6) | |
| “We travel thanks to the pharmaceutical companies and we go to congresses thanks to the pharmaceutical companies and inadvertently there is always some contact in some way because they have given us training, which our company didn't do...” (SI_Q7) | |
| “I suppose these are the questions that (patients) often keep asking themselves, due to ignorance of the professionals, due to pressure from pharmaceutical companies, the media... and they think that if you don't take it you will have a heart attack, sure.” (SI_Q8) | |
| “…. there is a lot of obesity, people eat very badly... you tell them, eat fish. Maybe fish is the most expensive thing there is, maybe that person cannot afford it... there are many factors at play.” (SI_Q9) | |
| I believe that the socioeconomic and cultural level of the patients is very important because it's the people who have a lower cultural and socioeconomic level who are the ones we should invest in more, though it is harder for us, we know that we have to try harder. (SI_Q10) | |
| Emotion | “Then too, the issue of the reliability of the guidelines is an issue... the sensitivity and specificity you have when making a decision... the issue of cholesterol is quite controversial.” (Em_Q1) |
| “Perhaps I should also add, to all these causes which are variable, that at the beginning it was necessary to treat cholesterol no matter what. So perhaps we also have that inertia internalized, followed by all the other factors. The cholesterol figures have been very variable, we did not know if it was necessary to treat it in primary or secondary prevention, and then it was clarified and it was in secondary, not in primary, diabetics are secondary, if they are not... there we have also had a bit of a mess so that could also be the cause of this prescription. (Em_Q2) | |
| “I think it also affects you a bit, that little voice in the head that we all have, that maybe you still find a cholesterol level of 300 with low cardiovascular risk and you say, uff, they have 300, the risk is 2 and a half... and even though you yourself have explained to the patient and others, that also influences things, I mean, what if... and then there's what [name of healthcare professional] said about the penetration on the subject of cholesterol in all areas, which makes you always think about it, and say, what if I don't treat them?” (Em_Q3) | |
| It is much harder to change the habits of someone who comes to check their cholesterol when they are 40 or 45, when they are set in their ways, which are difficult to change... it is harder than ‘Give me a pill so that I will do it quickly and have peace of mind’. (Em_Q4) | |
| The ease, it is very easy to prescribe and it is also easily observable with the figures, that's it,... You feel good and the patient too (Em_Q5) | |
| “If you can get a patient to lose those kilos and on top of that stop smoking, there is no tool to measure it, but that's a great satisfaction.” (Em_Q6) | |
| Behavioral regulation | I always comment on a lack of quality in the health center… and I still see that we do not stop and think, that there is no culture of quality evaluation, of demanding minimum standards and it seems to me that it's the most serious thing wrong with the public services. (BR_Q1) |
| I think [data] is useful and we are all open to using it. When you are under this healthcare pressure, you are not aware of the way you are working day to day, if you see 30 patients a day, you do not remember if you have prescribed 2 statins or... I do not see it as intrusive, I see it as data, it helps me, it is a reflection. (BR_Q2) | |
| … Motivation is what drives everything, being aware of it. And for practical purposes I would ask the company for a tool…. I often want to see how my patients are doing, how many diabetics, under what conditions, but I can't. Before, we asked for this information and they gave it to us, but after a while you had to ask again... We shouldn't have to ask for it, we should be able to access it... to monitor yourself and do self-evaluation and then that's what would really change, if the company asks me, ‘Hey what are you doing?’… (BR_Q3) | |
| What was really useful for me in the center is to make small resolutions to make small changes that you are willing to make and that you feel capable of making, and once you have done them it is much better to keep them and then make a few more and If you have not been able to do them, you have to work on why not, if it was too excessive, if you think you can do a little less, if you can change it and solve it. (BR_Q4) | |
| Reinforcement | But [name of healthcare professional], if you don't comply, what happens? And if you comply, what happens? Nothing, neither positive nor negative incentives, so… (Re_Q1) |
| If you do it really well, and I do it really badly, they pay us the same, so… it doesn't matter. (Re_2) |