Table 3 Relevant TDF domains, sub-themes, summary of domain content and example quotes for interviews with patients with bronchiectasis (Stage 1)

Knowledge

Knowledge of treatment

Patients had a broad understanding of most treatments but inhaled antibiotics were less well understood. Disease knowledge was vague and misinformed, particularly for knowledge of disease progression. In most cases, patients thought that having disease and treatment knowledge improved adherence.

“I would have to find out exactly why I was put on it (new treatment)…I don’t think I would start taking it until I was satisfied.” (F10A)

Knowledge of disease

Skills

Treatment skills

Most patients felt they had competent treatment skills. However, other patients did not feel they could competently complete airway clearance and this was a barrier to adherence. Patients frequently used self-monitoring skills to monitor symptoms and inform decisions about adherence either by reinforcing their current adherence behaviour or prompting a change in behaviour.

“They (physiotherapists) taught me a method of just sitting up in bed and using the wedge and doing the drainage that way.” (F2NA)

Self-monitoring skills

Beliefs about capabilities

Psychological capability

Patients were generally confident in using inhalers and oral medication. Nebulised medications and airway clearance were viewed to be more complex and some patients felt that they lacked the psychological capability to do these treatments, often reporting that doing treatments was monotonous. Patients thought their physical capability to adhere would change if they were older, had physical disabilities or were experiencing a pulmonary exacerbation.

“I do do it myself but I don’t feel it’s as good as, em, someone doing it for you…you’re getting more attention than you’re giving it yourself.” (F6NA)

Physical capability

Beliefs about consequences

Beliefs about necessity for treatment

Most patients believed that improved symptoms and quality of life were positive consequences of adherence. Those who reported a lack of perceived symptoms or symptomatic improvement following treatment had a lower perceived need for treatment. Some patients also believed that there were potential negative consequences of adherence, such as harm caused by taking medicines.

“I don’t really need an antibiotic…if I stopped it for 2 weeks, 3 weeks, 4 weeks I wouldn’t feel any different.” (M3NA)

Beliefs about harm caused by treatment

Motivation and goals

Intrinsic motivation

The majority of patients had high intrinsic motivation to adhere and prioritised adherence over other commitments. Some patients struggled with intrinsic motivation for airway clearance and inhaled antibiotics. Patients reported a desire to avoid negative consequences of non-adherence (hospital admission, pulmonary exacerbations and decline in quality of life) as goals that increased motivation to adhere.

“I think, you’ve got to feel it within yourself that this is what you need to do (adhere to treatment).” (M14A)

Goal to avoid negative consequences

Social influences

Trust in HCPs

Patients expressed an inherent trust in HCPs. They stated that the support of HCPs and other people with bronchiectasis built their confidence in managing their condition. Generally patients reported that their families were supportive but some did not want to be a burden on their families and did not involve them in their treatment. Family, social and working commitments were seen by some as barriers to adherence.

“I do take them because they (HCPs) tell me to do that, you know, to take the whole course (of oral antibiotics).” (M16A)

Social support

Competing social demands

Behavioural regulation

Education

Patients suggested training on treatment skills, information on disease progression, reasons for doing treatment, expected treatment effects and negative consequences of non-adherence would encourage patients to adhere. Action planning and reminder strategies were suggested, with the caveat that the latter were only for those with difficulty remembering to do treatment. Access to and regular review by a specialist multidisciplinary team was thought to facilitate adherence. Several non-adherent patients thought that feedback on disease progression would facilitate adherence.

“If somebody came along and said to me, ‘if you don’t take that Acapella® or use that Acapella® every morning and night, eh, you’re going to get worse, your bronchiectasis is going to get worse’ then would probably frighten me into taking it.” (M5NA)

Action planning

Reminder strategies

Regular review

Feedback on outcome

Nature of behaviour

Routine

Most patients reported that adherence was something they did automatically. Most patients linked doing treatments to other activities such as mealtimes and bedtimes. Treatments that fell outside of the normal treatment routine or were more burdensome to integrate (e.g., airway clearance or inhaled antibiotics) were more likely to be missed.

“I tend to do mine (treatments) with my early morning cup of tea and when I’m in bed at night.” (F12A)