Table 5 Barriers and facilitators to implementation identified according to the TDF

Domain 1: Knowledge (n=13)

An awareness of the existence of something.

Level of awareness of potential health outcomes

Lack of awareness of the adverse health outcomes experienced by people with intellectual disability [12, 32, 48] (n=3)

Awareness of the adverse health outcomes experienced by people with intellectual disability [12, 30, 43, 44] (n=4)

Level of awareness of existence of assessments

Lack of awareness of the existence of, or what is entailed in, health assessments for patients with intellectual disability [12, 31, 36] (n=3)

Awareness of the existence of health assessments for patients with intellectual disability [31, 45] (n=2)

Comprehension of health benefits of assessments

Lack of awareness of the determined health benefits of health assessments [30, 31, 33, 45, 46, 50] (n=6)

Awareness of the determined health benefits of health assessments [30, 34] (n=2)

Comprehension of specific codes in clinical information systems and preventive care guidelines

Limited knowledge on specific codes and guidelines, such as those used to identify patients with intellectual disability in their clinical information system [32, 50], and preventive care guidelines [31] (n=3)

Domain 2: Skills (n=16)

An ability or proficiency acquired through practice.

Ability to communicate effectively with patient

Lacking the necessary communications skills or perceiving communication difficulties as a barrier to conducting a health assessment [30, 32, 34, 40, 41, 48] (n=6)

Possessing the necessary skills to conduct a health assessment, such as communication [40] and addressing patients with intellectual disability in a respectfully sensitive manner [42] (n=2)

Level of training and experience underpinning work with patient group, including reasonable adjustments

Identification of further training needed to improve patient care

Lack of existing training and experience with patients with intellectual disability [31, 32, 34, 45, 47, 48], including understanding what reasonable adjustments are and how to implement them [12, 48, 50] (n=8)

Identification of recommended areas of training such as further education on provision of care of people with intellectual disability [31,32,33, 38, 44, 50], specific training on performing health assessments [33, 34, 36], and exposing practitioners to health care needs of people with intellectual disability in their training [31, 47] (n=9)

Domain 3: Social/Professional Role and Identity (n=10)

A coherent set of behaviours and displayed personal qualities of an individual in a social or work setting.

Personal views on role of primary care to deliver health assessments

Clarity of role of primary care practitioners in delivery of health assessments

Belief that health assessments should not be delivered by primary care services [37, 43, 45] (n=3)

Further clarity on requirements of role requested [30, 34] (n=2)

Acceptance of primary care provider’s role in delivering health assessments [31,32,33, 37, 45, 47, 50] (n=7)

Beliefs around who is responsible for follow-up care

Concerns regarding whose responsibility it will be to follow-up on any required actions as a result of assessments [47] (n=1)

Acknowledgement of the importance of planning follow-up to the health care assessment (i.e. referral to specialist services if required) [50] (n=1)

Domain 4: Beliefs about Capabilities (n=7)

Acceptance of the truth, reality or validity about an ability, talent or facility that a person can put to constructive use.

Level of confidence in ability to perform health assessments

Indicating a low level of self-confidence in one’s own and other practitioners’ abilities to conduct health assessments [12, 32, 39, 46] (n=4)

Indicating a high level of self-confidence in one’s own and other practitioners’ abilities to conduct health assessments [12, 31, 34, 47] (n=4)

Domain 5: Optimism (n=9)

The confidence that things will happen for the best or that desired goals will be attained.

Overall view on health assessments being worthwhile and will improve overall health outcomes

General belief that health assessments are not worthwhile and will not improve the overall health and wellbeing of people with intellectual disability [30, 31, 34, 45, 46, 48] (n=6)

General belief that health assessments are worthwhile and will improve the overall health and wellbeing of people with intellectual disability [12, 30, 31, 33, 34, 47, 48] (n=7)

Domain 6: Beliefs about Consequences (n=10)

Acceptance of the truth, reality or validity about outcomes of a behaviour in a given situation.

Whether health assessments contribute to knowledge and skills for practitioners, support workers and collaboration together

Belief that the process of doing health assessments enhances the knowledge and training of practitioners [12, 32, 47] or support workers [30, 48], and their collaboration together [44, 47] (n=6)

Overall view on effectiveness for health outcomes

Belief that more evidence is still required to indicate the benefits of health assessments [31, 32, 43] (n=3)

Belief that health assessments will truly improve objective health outcomes for patients with intellectual disability who utilise them, such as the detection of previously unidentified or preventive health problems and delivery of proactive care [30, 32, 44, 45, 47, 48, 50] (n=7)

Level of benefit for practitioner-patient relationship

Belief that health assessments improve the practitioner–patient relationship [32, 47, 48] (n=3)

Domain 7: Reinforcement (n=7)

Increasing the probability of a response by arranging a dependent relationship, or contingency, between the response and a given stimulus.

Adequacy of financial compensation

Belief there is a lack of adequate financial compensation for the time required to prepare for and conduct a health assessment [12, 32, 38, 47, 48] (n=5)

Belief there is adequate financial compensation for the time required to prepare for and conduct a health assessment [31, 42] (n=2)

Domain 8: Intentions (n=9)

A conscious decision to perform a behaviour or resolve to act in a certain way.

Interest in prioritising heath assessments

Lack of interest in prioritising and providing health assessments to people with intellectual disability [30, 36, 42, 47, 48] (n=5)

Invested interest in prioritising and providing health assessments to people with intellectual disability [33, 42, 45, 50], including provision of reasonable adjustments a priority [36, 39, 48, 50] (n=7)

Domain 9: Goals (n=1)

Mental representations of outcomes or end-states that an individual wants to achieve.

Willingness to set clear and defined goals

Clear and defined goals to promote uptake of health assessments [42] (n=1)

Domain 10: Memory, Attention and Decision Processes (n=7)

The ability to retain information, focus selectively on aspects of the environment and choose between two or more alternatives.

Use of staff reminders

Utilisation of reminders to alert staff of upcoming health assessments [42] (n=1)

Availability of fit-for-purpose patient registry

Insufficient, or inability of, pre-existing patient registry to identify eligible people with intellectual disability [32, 33, 36, 42, 43, 48, 50] (n=7)

Domain 11: Environmental Context and Resources (n=18)

Any circumstances of a person’s situation or environment that discourages or encourages the development of skills and abilities, independence, social competence and adaptive behaviour.

Views on capacity and effectiveness of support workers

General concerns about the capacity of support workers to contribute to the process (i.e. lack of knowledge of relevant medical background or to implement actions arising from health assessments) [30, 31, 40, 41] (n=4)

General belief that support workers are useful in the implementation and flow of health assessments [31, 33, 40, 41, 45, 48, 50] (n=7)

Availability of support staff

Unknown, or lack of, support workers [30, 38] or allied health workers and specialists to refer to or seek assistance from [31, 32, 37, 48] (n=6)

Others who aren’t primarily in charge of providing the health assessment, including support staff [31, 32, 45] and specialist services [32, 33, 37, 43] (n=6)

Adequacy of resources available to promote the delivery of health assessments

Whether enough time is available to perform health assessments

A perceived lack of general resources to support the implementation of health assessments [12, 32, 42, 48] (n=4)

Inadequate time available or allocated for provision of health assessments [30,31,32, 34, 38, 42, 47] (n=7)

Tools such as the health assessment proformas (e.g. CHAP, Cardiff) [30, 44, 47, 48], ability to access patient histories [31, 34], and electronic formatting of the checks [42, 47] to hasten the process. (n=7)

Patient-related factors that may influence uptake of health assessments

Concern about patient-related factors that act as a deterrent to the uptake of health assessments, such as lack of demand [46], limited access to health care [30], inability to contact [48], and extended length of appointment [42] (n=4)

Domain 12: Social Influence (n=5)

Those interpersonal processes that can cause individuals to change their thoughts, feelings or behaviours.

Perceptions of support to promote the uptake of health assessments

Perceived support to promote the uptake of health assessments from agencies [37, 47], communities [31, 44] or colleagues [50] (n=5)

Domain 13: Emotion (n=12)

A complex reaction pattern, involving experiential, behavioural and physiological elements, by which the individual attempts to deal with a personally significant matter or event.

Personal attitudes towards performing health assessments

Generally negative affect towards performing health assessments (i.e. anxiety [33], burnout [34, 37, 38, 43, 45, 46], aversion to checklists [32] (n=8)

Generally positive affect towards performing health assessments (i.e. satisfaction [33, 34, 47], eagerness [32, 47, 48, 50]. (n=6)

Level of comfort with how patient perceives health assessments

Fear of inadvertently stigmatising the patient [32, 42] (n=2)

Domain 14: Behavioural Regulation (n=5)

Anything aimed at managing or changing objectively observed or measured actions.

Organisational factors limiting/aiding health assessment delivery

Organisational and/or logistical issues identified such as troubles with coordination of all parties [30] and issues with the primary care interface [50] (n=2)

Enacting, or intent to enact, changes perceived to promote the uptake of health assessments (i.e. dedicated intellectual disability lead [36, 50] and automatic reminders [42]. (n=3)

Importance of seeking feedback from patients

Seeking feedback from patients [33, 42, 50] (n=3)