Table 4 Relevant TDF domains, sub-themes, summary of domain content and example quotes for interviews and focus groups with HCPs (Stage 1)

Knowledge

Clinical knowledge

Primary care HCPs lacked knowledge about bronchiectasis and its management. Better HCP disease knowledge was thought to translate to better patient disease knowledge. HCPs had a broad understanding of the potential barriers for patient adherence to treatment. Some HCPs stated that they did not know what to do to change patients’ adherence.

“There’s probably not as much knowledge (about bronchiectasis) as there maybe should be.” (I4_PN)

Knowledge of adherence

Skills

Interpersonal skills

HCPs stated that they used interpersonal skills such as questioning skills, building rapport, negotiation, problem-solving and persuasive communication to change adherence. Some HCPs felt that they lacked these skills. Some HCPs had formal postgraduate training in interpersonal skills, which they thought improved their ability to change patient adherence.

“I think we would just rely on experience. I don’t think you’re ever given any specific training about adherence in any aspect.” (FG1_HP)

Beliefs about capabilities

Confidence in ability to change adherence

HCPs had a general belief that they had limited control over changing patients’ adherence. Some lacked confidence in their ability to change adherence. Others felt confident in their ability to do this and those who did, tended to have completed extended communication skills training. Several participants appeared pessimistic about their ability to change their own behaviours around managing adherence, this was mainly linked to limitations due to environmental constraints.

“I kind of dread the patient who I think isn’t compliant…the ability to honestly challenge a patient about their compliance without perhaps losing the relationship, the trust and stuff… It’s actually a quite challenging thing.” (FG5_D)

Confidence in ability to change own behaviour

Beliefs about consequences

Positive consequences of changing adherence

HCPs believed that changing adherence could lead to positive consequences for the healthcare system and patients, through reduced hospital admissions and financial burden. They evaluated the need to change patients’ adherence based on their disease status. They only asked questions about adherence when patients were unwell. Some HCPs were concerned about the negative consequences of discussing adherence, such as sabotaging their relationship with that patient and a potentially increased workload.

“(Nurse’s name) and I are trying to do the bronchiectasis service on top of our (usual workload), which is a problem, so you know, in terms of chasing up adherence and chasing up patients to see what they’re doing isn’t always as possible.” (FG3_PT2)

Negative consequences of changing adherence

Motivation and goals

Adherence not a priority

Changing adherence was not a priority for HCPs unless patients were unwell or there was a reason to suspect non-adherence. Bronchiectasis was not a priority for primary care participants, who viewed it as a secondary care problem.

“If they’re not under the umbrella of asthma or COPD, well it doesn’t matter whether they’re seen or not [laughs] in theory.” (I1_PN)

Bronchiectasis not a priority for primary care

Social influences

Influence of patients

Patients strongly influenced HCPs’ clinical decisions about adherence. Involving patients in decisions about treatment and adherence was viewed as being essential to changing adherence. Effective team working was thought to increase HCPs’ ability to manage adherence. A lack of team-working was evident between primary and secondary care.

“If the GP changes something or if they (patients) go to hospital and something has changed…nobody lets the community pharmacist know…you sort of fall out of the loop a wee bit” (FG7_CP)

Influence of other HCPs

Behavioural regulation

Patient-focused strategies

HCPs suggested patient-focused adherence strategies such as disease education, goal setting, action planning, problem-solving, social support, feedback about disease progression/adherence. System-focused strategies included a clear, multidisciplinary pathway across primary and secondary care. Suggested strategies to monitor adherence included electronically chipped inhalers, patient diaries, counting tablets and questioning patients about adherence. HCP-focused training on consultation skills was also recognised as being needed.

“(We need) something that has everything in one book, you know, to explain medications, airway clearance, exercise, self-management, anxiety, depression all of those things in one booklet.” (FG7_PT2)

System-focused strategies

HCP-focused strategies

Nature of behaviours

Changing adherence not part of routine care

HCPs stated that changing adherence was not part of current routine assessment and treatment for patients with bronchiectasis. However, they recognised that data on number of prescriptions are routinely collected by GP and pharmacy databases and thus, could be made available from primary care to secondary care to enable monitoring of dispensed items.

“When you’re seeing a bronchiectasis patient you’re not automatically thinking of adherence.” (FG3_N1)