Referral to and Engagement with Pulmonary Rehabilitation: A Review and Strategic Behavioural Analysis of Factors Influencing Behaviour and Intervention Opportunities

Amanda P Moore,1 Isolt Reardon,1 Osanna Ramkissoon,1 Frances Early,2 Estelle Payerne,3 Polly-Anna Ashford,3 Stephen Holmes,4 Michael P Kelly,5 Sally J Singh,6 GM Monsur Habib,7 Jonathan Fuld,8 Fabiana Lorencatto1 On behalf of the UPTURN Team1Centre for Behaviour Change, University College London, London, Greater London, UK; 2Research and Development, Cambridge University Hospitals NHS Foundation Trust, Cambridge, Cambridgeshire, UK; 3Norwich Clinical Trials Unit, University of East Anglia, Norwich, Norfolk, UK; 4The Park Medical Practice, Shepton Mallet, Somerset, UK; 5Department of Public Health and Primary Care, University of Cambridge, Cambridge, Cambridgeshire, UK; 6Centre for Exercise and Rehabilitation Science, University of Leicester, University Hospitals Leicester NHS Trust, Leicester, Leicestershire, UK; 7Mymensingh Medical College, The University of Edinburgh, Edinburgh, Midlothian, Scotland; 8Victor Phillip Dahdaleh Heart and Lung Research Institute, Cambridge University Hospitals NHS Foundation Trust, Cambridge, Cambridgeshire, UKCorrespondence: Amanda P Moore, Centre for Behaviour Change, University College London, Greater London, UK, Email amanda.p.moore@ucl.ac.ukBackground: Despite strong evidence of benefit, in the UK only 40% of eligible patients are referred to Pulmonary Rehabilitation (PR) and there are poor levels of uptake and completion globally. Understanding how current interventions address reported barriers to PR referral and engagement can help understand intervention effectiveness and highlight opportunities for future policy and intervention.Methods: Two systematic reviews were conducted: 1) Review of studies reporting barriers/enablers to PR delivery and engagement behaviours, with extracted barriers/enablers inductively synthesized into themes and coded to the domains of the Theoretical Domains Framework (TDF). 2) Review of existing interventions to improve PR uptake/engagement, specifying component Behaviour Change Techniques (BCTs) using established taxonomies. Interventions were categorised for promise according to evidence of change in behaviour for one or more outcomes. Findings from both reviews were triangulated using the Theories and Techniques tool (TaTT), to assess the extent to which components in current interventions targeted key barriers/enablers.Results: Sixty-three studies were included in the analysis. Barriers and enablers to PR mainly fell under the TDF domains Environment, context and resources; Knowledge; Social Influences; Professional role and identity; and Memory, attention and decision making. There are opportunities to further support referral by considering interventions targeted at memory and decision making and by streamlining referral processes. For patient engagement with PR, the highly represented TDF domains were Environment, context and resources; Social influences; Emotions; Knowledge; and Beliefs about capabilities. Fifty-four percent of referral interventions and 15% of engagement interventions were considered very promising. BCTs in promising interventions targeting patient engagement included provision of social support and guidance on planning and goal setting. Opportunities for improving engagement include consideration of the emotional burden associated with COPD and attending PR.Conclusion: These findings can inform development of new, or refinement of existing, interventions targeting PR for people with COPD.