Barriers and enablers of physical activity engagement for patients with COPD in primary care

Figures & data

Table 1 Participants’ characteristics

Characteristics	Group 1 (Employed)	Group 2 (Recently diagnosed)	Group 3 (PR)	Group 4 (Mixed)
Age group, years
50–59	2	0	1	0
60–69	3	4	5	2
70–79	0	2	1	4
80–89	0	0	1	1
Sex
F	3	3	2	2
M	2	3	6	5
MRC dyspnea score
MRC1	3	2	2	0
MRC2	1	3	1	3
MRC3	1	1	3	2
MRC4	0	0	1	2
MRC5	0	0	1	0

Notes: MRC1: Not troubled by breathlessness except on strenuous exercise; MRC2: Short of breath when hurrying or walking up a slight hill; MRC3: Walks slower than contemporaries on level ground because of breathlessness or has to stop for breath when walking at own pace; MRC4: Stops for breath after walking ~100 m or after a few minutes on level ground; MRC5: Too breathless to leave the house, or breathless when dressing or undressing.

Abbreviations: PR, pulmonary rehabilitation; F, female; M, male; MRC, Medical Research Council.

Figure 1 Personal barriers and enablers.

Abbreviation: PA, physical activity.

Figure 2 Social barriers and enablers.

Table 2 Summary of previous research studies: barriers and enablers to physical activity in patients with COPD

Study	Aim/question	Sample population characteristics	Design and methods	Results: main barriers identified	Results: main enablers identified	Conclusion and themes of study
Thorpe et al^Citation19	To identify barriers and enablers of PA 2 months after hospital admission in people with COPD	• 28 people (male =22) • Mean age =71.9 years  Mild (n=2)  Moderate (n=5)  Severe (n=21) • Average length of stay in hospital: 6.61 days • Australian sample	• Qualitative • 28 semi-structured telephone interviews • Content analysis	Three main barriers identified with relevant subcategories: 1. The self:  a. Advancing age  b. Lack of access to oxygen therapy  c. Negative experiences of PR (eg, lack of follow-up/intensity) 2. Health:  a. Comorbidities  b. Physical injury or sickness (eg, back pain) 3. Environment:  a. Surroundings (eg, effect of weather)  b. Transport/finance	Three main enablers identified with relevant subcategories: 1. Social:  a. Support (eg, family/friends)  b. Keep to a routine (ADL, eg, shopping and errands)  c. Extracurricular activities (eg, hobbies) 2. Personal (individual centric):  a. Feeling better (eg, positive outcomes from participation in PA and PR)  b. Goal setting and self-motivation 3. Access (eg, equipment and health professionals)	Conclusion: importance of individualized targeted approach Most commonly reported barrier: poor health Further research needed on enabling strategies for participation in PA Limitation: limited generalizability
Amorim et al^Citation31	To evaluate the ability of COPD patients to perform ADL, to identify barriers that prevent these individuals from performing ADL, and to examine the association between activity levels and barriers	COPD group: 40 patients treated at a pulmonary outpatient clinic (male =22) Mean age =64.4 years Control group (spouses of the COPD patients and other individuals treated at the clinic): 40 healthy elderly individuals (male =19) Mean age =66.7 years • Brazilian sample	• Cross-sectional study • mMRC to determine severity of baseline dyspnea • Triaxial accelerometer to measure PA • Questionnaire to assess PA barriers (based on US CDC recommendations) • LCADL scale • 6MWT	Barriers identified: 1. Lack of time 2. Social influences 3. Lack of energy 4. Lack of willpower 5. Fear of injury 6. Lack of ability 7. Lack of infrastructure	Enablers are not actively identified in this study … But Suggestions offered to overcome the identified barriers: • Greater encouragement • More resources • Education among family members regarding disability	Conclusion: patients with COPD are less active than healthy adults Most commonly reported barriers: lack of infrastructure, lack of willpower, and social influences
Hartman et al^Citation18	What are the perceived reasons for people with COPD to be physically active or sedentary? Are those reasons related to the actual measured level of PA?	• 115 people (male =78) • Mean age =65 years • Mild to very severe COPD • Dutch sample • Exclusion criteria: serious active diseases or treated for an exacerbation during previous 2 months	• Observational study with qualitative element • Semi-structured interviews • Triaxial accelerometer (to measure PA) • Spirometry • mMRC (to assess dyspnea severity) • Two 6MWTs • Inductive content analysis	Four perceived reasons not to be physically active (barriers to improved health): 1. Poor weather (reported by 48% of participants) 2. Health problems (43%) 3. Lack of intrinsic motivation (11%) 4. Positive social support (50%)	Four perceived reasons to be physically active (enabling improved health): 1. Health benefits (reported by 65% of participants) 2. Enjoyment (44%) 3. Continuation of an active lifestyle in the past (28%) 4. Functional reasons (26%)	Conclusion: importance of increasing self-efficacy and tailoring the type of activity instead of a standardized PA program Themes: consistent with previous studies; enjoyment as motivation for PA is a key new theme in this study
Mathar et al^Citation29	To explore reasons why patients with COPD decline PR	Seven qualitative studies included in review (two from Australia, five from UK) Inclusion criteria: • Qualitative studies published in English • Studies with a patient perspective Exclusion criteria: • Reviews • Intervention studies • Lack of patient perspectives • Qualitative with high dropout or non-completion	• Metasynthesis of previous qualitative studies • Metaethnography • Five studies face-to-face interview • One study telephone interview • One mixed study (both face-to-face interview and telephone interview)	Four barriers identified in patients declining rehabilitation: 1. The referral process:  a. Attitude of health care professional  b. Lack of information about the process of referral and follow-up 2. Transportation and its financial burden (eg, no car or inability to use public transport) 3. Perception of health and self (eg, feelings of being too old or ill to participate) 4. Other obligations or priorities (eg, care-giving, pet care, or afraid to leave house unattended)	N/A to paper	Although: similar themes identified among the seven studies However: different aim of the studies and varied definitions Conclusion: make PR more accessible: a. At more flexible times b. In patients’ homes c. Transportation Most commonly reported barriers: the referral process, transport problems, and self-perceptions
Thorpe et al^Citation17	To identify potential barriers and enablers, associated with their participation in PA programs, including PR	Systematic review based on 11 studies (eight qualitative, three quantitative)	• Reviewers independently evaluated the methodological quality of the chosen papers using the McMaster critical appraisal tool	Six barriers to participation in PA and PR programs: 1. Personal issues (eg, anxiety/fear about exercise) 2. Changing health status (eg, comorbid conditions) 3. External factors (eg, weather/finance) 4. Lack of support (motivational) 5. Program related (the influence of medical practitioners) 6. Smoking (studies showed that smokers were less likely to have high attendance at PR)	Seven enablers for participation in PA and PR programs: 1. Personal drivers (self-motivation) 2. Personal attributes and perceived health benefits (persistence and positivity) 3. Social support (network formed through PR) 4. Control of condition (goal setting) 5. Program-centric enablers (safe environment and quality care) 6. Professional support (before, during, and after treatment) 7. Goal setting	Conclusion: identifies an evidence-practice gap in delivering treatment: good evidence to support the health benefits of PR, but poor implementation of PR in clinical practice. Themes: motivation and goal setting as incremental enablers
Sohanpal et al^Citation30	To explore factors affecting patient participation in COPD support programs	• Thematic framework synthesis on 10 of 12 studies • Studies included from 1984 to 2015	• Qualitative synthesis Theoretical frameworks used: a. “Attitude-social influence-external barriers” model b. “Self-regulation” model	Three main barriers and enablers: 1. Attitude (perception of the program as positive or negative) 2. Social influences (the positive or negative influence of the health professionals, friends, and family members in participation) 3. Intervention representations (a positive or negative perception of the support program on offer)	All three themes can be considered a barrier or enabler dependent on its positive or negative perception/experience	Conclusion: patient participation in programs is largely influenced by the participant’s attitude and social influences they are subjected to

Abbreviations: PA, physical activity; PR, pulmonary rehabilitation; ADL, activities of daily living; mMRC, modified Medical Research Council; LCADL, London Chest Activity of Daily Living; 6MWT, 6-minute walk test; N/A, not applicable.

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