Stage 1: Understand the behaviours
The analysis identified eight domains of the TDF components that were relevant to nine themes thought to influence the PCPs perceptions on the implementation of POC. The TDF domains included: (1) knowledge; (2) behavioural regulation; (3) reinforcement; (4) skills; (5) environmental context and resources; (6) social influence; (7) professional role and identity; and (8) belief about consequences. Table 2 provides an overview of how the themes, belief statements, and occurrences are mapped to the TDF domains.
Mapping of themes with the Theoretical Domains Framework
PCPs had limited knowledge of the SARS-CoV-2 POC testing landscape. This acted as a barrier as they were unable to identify the advantages or disadvantages of implementing POC tests into practice.
“I think there is a huge gap in knowledge around what point-of-care, antigen tests look like, how they work, the level of confidence we can have in the results and we're hearing that even reading the results is variable.” (GP 21)
There was some scepticism about the insufficient evidence around the use of the tests and to confirm the validity of the devices.
“It seems that most of the devices seem to be on based on a lateral flow model and I am not aware of any that have sort of received proof that they are valid and can be used as a decision-making tool in clinical practice. But as I say, I've not sort of looked into detail about what there is more broadly out there.” (GP 08)
Although PCPs had some experience with providing service for other respiratory conditions requiring sample collection, they expressed the need for some support in terms of ‘professional education and training’ to operate the tests efficiently.
“All the people that work in the practice can take blood and do swabs, and quite a lot of us do respiratory stuff, spirometry and other breathing things. With simple training, we should be able to manage a point of care test that is simple, and it's making sure it can be done repeatedly and accurately”. (GP 16)
PCPs mostly referred to the need for health care assistants (HCAs) to receive training and take on the role as the main operators of the test.
“I think it'd have to be a health care assistant specifically trained up to do that… it's a skill that needs to be learned, but it's quite a simple one. You need someone who's focused on just that one problem” (GP 15)
Official guidelines or recommendations to provide POC testing meant that PCPs would adopt POC tests if prescribed by authorities.
“If it was recommended by Public Health England or NICE, I think we would follow the guidelines. And the problem is that they are just changing so quickly, we have to rely on you know, the sources we've got available. So yeah, so if I think Public Health England said to us this test is a good test. You’re all using it, and then we'd have to trust it.” (GP 02)
Another elaborated that they are obligated to follow guidance issued by their Clinical Commissioning Groups.
“General practices operate under the guidance from the local CCG and obviously the local CCG get advice from the NHS England in terms of what how we respond, and how we deal with things really. So, you would say the system level of how we operate is always based on the instruction there.” (GP 11)
Physicians mentioned that they would integrate testing into practice if they received financial incentives.
“If you provide the machines, and you provide the consumables, and you pay for our time, we will do it.” (GP 01)
Environmental context and resources
PCPs had limited workload capacity and were concerned that testing would add to existing pressures they already face. Existing work would need to be alleviated or compromises would have to be made to create capacity for testing.
“If we're adding something new in… say there's no new money, which too often isn't, something else has to be taken away. It's just not feasible to carry on doing everything and add in an extra thing.” (GP 04)
For many, there was a need for additional funding to hire extra staff and additional expenses associated with testing.
“Adding point-of-care testing for COVID positive patients to our surgery, without adding staff and space…it won't work.” (GP 14)
Participants discussed the influences of information sharing across practices on their perception of POC tests. For instance, some PCPs mentioned that they were wary of POC tests based on the concerns expressed by colleagues.
“But I think the general feeling I have, and I think most of my colleagues in the practice have is a lot of concern about that are they validated, and things like that, and our feeling, probably, broadly speaking, would be that it's widely talked about by the government, but that would seem to be a political exercise.” (GP 08)
PCPs also mentioned that information is regularly shared across technologically mediated communication platforms such as WhatsApp and Facebook.
“In terms of diagnostics, people have talked about it, but I've not really seen any kind of evidence-based information in those groups [social network platforms] yet about if there is one available for rapid testing. I mean, people have talked about that, posted articles which have been in the media.” (GP 10)
Professional role and identity
Most interviewees perceived that the responsibility for administering POC testing should not primarily fall within the remit of primary care. There was a general feeling the society will view primary care as an alternative to community testing centres.
“There's a risk that we will start to get an increased demand of having a doing testing on people who are on have would fit in that category of mild symptoms and not needing a face-to-face appointment and that obviously has resource implications in terms of time and staff and staff costs from salaries.” (GP 08)
Another explained why they thought the change in perception would happen,
“From a patient's perspective, not surprisingly, that is very attractive. So, it doesn’t take a genius to work out that if you as a patient can get a near patient test for COVID, that's going to be a very attractive commodity for patients.” (GP 05).
Beliefs about consequence
PCPs believed that the perception of assurance/risk played an important role. If the devices assisted them ruling-in and ruling-out potentially infectious individuals, they would feel more confident about the benefits of POC tests and face-to-face appointments.
“It will make us more confident in face-to-face consultations. We've got a huge population with respiratory illness, especially COPD. I think these are the patients who kind of have missed out on getting seen, because any respiratory symptom they have an exacerbation, we really are relying on our clinical acumen and a kind of basic saturation maximum. Because we tend not to bring them in. So, these are the kind of patients especially with respiratory symptoms, who would benefit from a rapid testing, because then we can actually see them, or the patients who have weak symptoms who we don't know if they have got COVID or not.” (GP 10)
However, several expressed concerns about occupational exposure. POC testing would equally place the practice staff at higher risk of getting infected and losing manpower.
“One of the key vulnerabilities in this is the sustainability of the general practice service. You know, what we want to do is make sure that we don't lose people, we don't have to self-isolate... So, we're losing manpower, and therefore productivity and sustainability.” (GP 21)
Stage 2 and 3: Identify intervention options, content and implementation options
As outlined in the methods section (step 3), seven intervention functions from the BCW considered useful included ‘education’, ‘persuasion’, ‘training’, ‘enablement’, ‘incentivisation’, ‘environmental restructuring’, and ‘restriction’. The most common were ‘persuasion’ and ‘education’, which largely addressed the influence of knowledge and the role of information sharing. Following this, we used the 93-item BCT taxonomy to identify 18 specific behaviour change techniques to map to the intervention function that we considered would be relevant in a future intervention. Examples of intervention functions for ‘training’ was mapped to the BCT technique ‘instructions on how to perform the behaviour’ to target staffs need for training support in learning how to use POC tests. The most common techniques used were ‘Information about social and environmental consequences’ (e.g., Provide evidence-based information to cultivate confidence in the quality of POC tests). On this basis and as described in the methods, intervention strategies were further developed and refined through discussion with a groups of physician colleagues who were part of our member checking team and were knowledgeable in care pathways analysis and evaluation of POC diagnostics. The final mapping and linkage of the relevant themes, TDF constructs, and intervention types, behaviour change techniques, and implementation strategies based can be found in Table 3.