Table 4 Barriers and enablers for individual CFIR domain with TDF

Capability

STs: 9B and 5E

Knowledge

Knowledge and awareness

STs: 3B and 1E

^aLack of knowledge or awareness of condition and/or management of condition (P, HCP) [35, 36, 39,40,41, 43, 45, 52,53,54]

^aLack of knowledge about NDIs or conservative management (P, HCP) [18, 36, 38, 42, 44, 45, 52, 53, 55]

Low general health literacy (P) [51, 58]

^aKnowledge about the condition and/or condition management (P) [36, 43, 47, 54, 55, 57]

Skills

Health condition management skills

STs: 3B and 3E

^aLack of skills to clearly and effectively communicate about benefits, harms, or lifestyle changes (HCP) [40, 41, 43, 44, 53,54,55]

^aLack of skills to effectively self-manage condition (P) [38, 40, 48, 54, 55]

Lack of experience in managing condition with NDI (HCP) [41, 43]

^aSkills to effectively self-manage condition (P) [38, 40, 43, 46, 47, 52, 57]

Good general coping skills (P) [47, 54, 55]

Clinician skills to support patient, including motivation and monitoring (HCP) [41, 45, 47]

Memory, attention and decision processes

Memory and decision making

STs: 2B

Forget to engage in NDI (P, HCP) [38, 44]

Energy limitations due to health condition impacts decision between life activities and NDI (P) [37, 42]

Behavioural regulation

Routine and adherence

STs: 1B and 1E

Difficulties adhering to condition management program that uses NDI (P) [41, 46, 57, 58]

Day to day routine that enables and prioritises condition management with NDI (P) [38,39,40, 47, 55, 57]

Opportunity

STs: 8B and 6E

Environmental context and resources

Personal circumstances and resources

STs: 6B and 4E

^aSymptom of condition (e.g., pain, fatigue) interfere with engagement in NDI (P) [35,36,37,38,39, 42, 43, 47, 49, 51, 52, 55, 56, 58]

^aOther comorbidity interfere with engagement in NDI (P) [38, 40, 49, 50, 52, 54, 55]

Personal financial disadvantage (P) [38, 39, 51, 58]

^aPersonal and family stressors interfere with engagement in NDI (P) [37, 38, 40, 46, 47, 52, 53, 55]

Current lifestyle interferes with engagement in NDI (P) [52]

High demands of NDI limit engagement (P) [47, 55]

Ability to engage in NDI at home (P) [37, 47]

Disease condition is stable (P) [47]

Time available to engage in NDI (P) [47]

Having a pet (P) [39, 49]

Social influences

Influence of others and community

STs: 2B and 2E

Concerns about being a burden (P) [40, 42]

Comparison of self to others (P) [35, 55]

People facilitating NDI in the community were understanding and encouraging (P) [36,37,38]

Engagement with religion supported emotional changes (P) [58]

Motivation

STs: 18B and 15E

Social or professional roles and identity

Roles and identities

STs: 1B and 3E

Loss of identity or capacity as a result of health condition (P) [35, 36, 38, 39, 55]

HCPs perceive delivery of NDI to be a part of their role, and act on this (HCP) [18, 39, 52]

Engagement with NDI doesn’t interfere with ‘normal’ function, sense of self or identity (P) [36, 39, 46, 57]

NDI becomes part of sense of self or identity (P) [46]

Beliefs about capabilities

Confidence and self-efficacy

STs: 3B and 2E

Low self-efficacy and confidence to manage condition (P, HCP) [38, 40, 43, 46, 52, 57]

Lack of confidence to use tools associated with NDI (P, HCP) [40]

Overconfidence in current knowledge about NDI (P) [18]

Confidence to engage in discussion about NDI with patients (HCP) [18, 43]

Self-efficacy and confidence to self-manage condition with NDI (P) [40, 42, 47, 57]

Optimism

Outlook on health condition

STs: 1B and 1E

Negative attitude towards NDI (P) [35, 38]

Attitude of positivity and optimism towards NDI and health condition management (P) [35, 36, 39, 48, 49, 57]

Intentions

Intention to engage in NDI

STs: 1B and 1E

Diagnosis of health condition triggers engagement in NDI (P) [39]

Uncommitted or unwilling to engage in NDI (P) [38, 40]

Goals

Goal setting and motivation

STs: 1B and 2E

Absence of goals around self-management/NDI (P) [40, 48]

Making plans and setting goals around condition management and NDI (P) [35, 36, 39, 40, 46, 47, 49, 56]

Motivated to engage in NDI (P) [39, 41, 47]

Beliefs about consequences

Beliefs and assumptions

STs: 5B and 1E

^aBelief that using a NDI is useless or harmful (P, HCP) [35,36,37,38, 40, 42, 43, 51, 52]

Assumptions about patient motivation deters clinician from offering NDI (HCP) [52]

^aDisbelief or denial about diagnosis inhibited engagement in NDI (P) [38, 40, 46, 53]

Making lifestyle changes perceived as too challenging (P) [46, 52]

Preference for alternative medicine (P) [40, 58]

^aNDI viewed as way to control condition and condition progression [35, 36, 39, 40]

Reinforcement

Reinforcement and feedback loops

STs: 1B and 3E

Self-monitoring tools onerous to maintain (P) [37, 38]

^aReminder/monitoring systems for progress, medication and symptoms are motivating (P) [37, 38, 40, 46, 52]

^aHealth improvements seen as result of engagement with NDI, prompting further engagement (P) [36,37,38,39, 42, 46, 47, 49, 55]

Prior positive experience with NDI (P) [37, 38, 45, 46]

Emotion

Emotions as a regulator of engagement

STs: 5B and 2E

Negative emotion (e.g., despondency, despair) associated with delivering the intervention (HCP) [18, 42, 43]

^aNegative emotion (e.g., fear, anxiety, powerlessness) inhibit engagement with NDI (P) [18, 38, 40, 46,47,48,49,50]

^aNegative emotion (e.g., depression, anxiety) impact general wellbeing, coping and self-esteem (P) [38,39,40, 42, 49, 51, 56]

Frustration with reduced capacity/independence that comes with health condition (P) [38, 49]

Negative emotion (e.g., scepticism, apathy, disappointment) towards NDI (P) [38, 45]

Feeling positive and safe when engaging in NDI (P) [37,38,39]

^aNegative emotion (e.g., guilt, shame) motivated engagement with NDI (P) [40, 46, 47, 52]