Physical activity recommendations for patients with heart failure
attitudes and experiences is recognized (12–13). Re-
commendations by healthcare professionals have also
been shown to be associated with higher levels of PA
(14). Patient adherence is, in turn, multidimensional,
and depends on motivations and barriers related to
patient-specific factors, the healthcare system, so-
cioeconomic factors and factors associated with the
prescribed therapy and the specific condition (8).
One factor associated with lower levels of adherence
with treatment recommendations is female sex (8).
Female sex is also associated with lower levels of PA,
both in the healthy population and in patients with HF
specifically, which is directly related to adverse health
effects (8, 15). The reasons for this discrepancy have
been studied in young people and, when examining
differences in PA between the sexes in general, women
report less self-efficacy (confidence in successfully
attaining a desired behaviour), less social support and
less motivation to exercise (15). However, in contrast
to the vast amount of research on sex differences in
HF, little HF-specific research has been published in
this particular area. Furthermore, in 1 of the few HF-
specific studies on this topic, women were found to
report higher levels of motivation than men, although
no difference in the level of PA was found (16).
The aim of this study was to investigate the percep-
tions that healthcare providers may have with regard
to sex differences in PA, motivations and barriers, and
whether adaptations in care based on sex differences
might be meaningful.
METHODS
Study design
This was a qualitative interview study conducted at 2 univer-
sity hospitals in Israel: Beilinson Hospital in Petah Tikva and
Soroka Hospital in Beer Sheva. Interviews were held during
February to May 2017.
Sampling
Participants (healthcare providers) were recruited for the study
using purposeful sampling, with the aim of including partici-
pants of different sexes and ages, participants with different
professions involved in HF care, and participants working at 2
different hospitals. As we were unfamiliar with the hospitals and
their employees, we were introduced to healthcare professionals
involved in HF care by cardiologists working at the hospitals.
They were then invited to participate in the study in person, by
e-mail or by phone call.
Ethical considerations
The Institutional Ethics Board of the Rabin Medical Center wai-
ved interview studies in healthcare personnel. All participants
provided written informed consent. They were also informed
that they could end the interview if desired, that their confiden-
tiality would be assured, and that data would not be shared in
533
a recognizable form with others. Furthermore, by not sharing
the characteristics and names of the participants, no quotations
in this paper can be traced back to the participant.
Procedure and interviews
Through literature review, a semi-structured interview guide was
developed building on the general aims and research questions
of the study. This guide comprised 2 parts addressing: (i) dif-
ferences and similarities in male and female HF patients with
regard to PA (e.g. “Do you think that male and female heart
failure patients might have different reasons to be active?”) and
(ii) perceptions on individualization of care based on patient’s
sex (for example “Do you adapt your practice to account for
sex differences in PA/capacity”). Pilot interviews were held
and the interview guide was revised before conducting a total
of 12 interviews, after which no new information came from
the interviews and the data were considered saturated. For
convenience, most interviews were conducted at the office of
the participant and the duration of the interviews ranged from
30 min to 1 h, depending on time restrictions. Twelve health-
care providers were interviewed, including 5 cardiologists, 2
residents, 3 nurses and 2 physiotherapists. The male to female
ratio of the sample was 1:1 and ages ranged from approximately
30 to 65 years. The interviews were conducted in English by a
(female) medical student (EC) (3 rd year) with limited experience
of HF management and attended by another (male) medical
student (AJ), who observed and assisted the first interviewer
when needed. The interviewers had no prior relationship with
the study participants.
Data analysis
The interviews were performed and transcribed concurrently.
The transcriptions were carried out, read through and summa-
rized by the first author (EC).
The data were analysed using qualitative content analysis,
according to Graneheim & Lundman (17). Each transcribed
interview was considered a unit of analysis. The units were
analysed one at a time, starting with repeated reading in order
to gain an overview of the content. The interviews were then
divided into meaning units, e.g. extracts from the unit of analysis
that describe the same central meaning. Meaning units were
then extracted, put into a table in a Word document and further
condensed. Condensed meaning units were then gathered in a
single collective document and sorted into groups, which in turn
were given codes. All codes were subsequently read through and
analysed for similarities and differences. They were then sorted
into categories, i.e. a grouping that one imposes on the coded
segments, in order to reduce the number of different pieces of
data in our analysis (“What is in the data?”).
To improve reliability, a discussion was held at this stage with
a second researcher (TJ), who is an experienced researcher with
an HF nursing background. Categories were revised, and codes
re-sorted. Based on this information, themes were derived, and
these were considered a higher level of categorization, used to
identify a major element of our entire content analysis (“What
is this about?”) (18–20). This was done with continuous feed-
back from the second researcher. Finally, an overarching theme
addressing the quintessence of the data was developed.
Several measures were taken in order to improve the trust-
worthiness of the analysis:
• To improve credibility, participants were chosen through
purposeful sampling, thus providing diverse insights into the
subject being researched.
J Rehabil Med 51, 2019