Table 2 Themes with representative quotations from focus groups and interviews
Themes and subthemes | Representative quotations |
|---|---|
1. Tool content | |
(a) Importance of messaging tone | |
Preference for positive messaging | “Yeah, I think the other point is that if we’re using this to—as a tool to urge people to quit, we want to keep the message as positive as possible. You don’t want too much fear in it, the down line plus the graphics there, you know, might be a little too negative” (R2, P2) |
Preference for negative messaging | “I think it would even be maybe more effective to say, increasing risk of COPD flares and death. Because again, most patients are probably going to be, in the visceral sense, more aware of what it’s like to have a COPD flare than the thought of their mortality.” (R1, C1) “I think it’s more meaningful if [the arrow beside the graph points] down […] This is where you’re going to end up.” (R2, P2) “It’s scarier if the arrows are going down.” (R2, P3) |
(b) Importance of Personalization | |
“…the fact that it’s personalized to the patient is very, very powerful, and it’s readily available. And then they leave with that in their hand, where it’s a story about them. I think that’s a very powerful thing.” (R3, C3) “Because this has happened to me, stage three, instead of puffing when you’re walking, use a walker, have a rollator there” (R3, P1) | |
(c) Importance of Lay Language | |
“What falls under COPD? Is that, like, asthma? Just any chronic obstructive pulmonary disorder? […] Yeah, I’ve heard emphysema and chronic bronchitis, but I didn’t know if asthma was classified as COPD.” (R1, P4) | |
(d) Scientific vs Intuitive Display Preference | |
Preference for scientific display (physicians) | “Those look like black dots. That looks like you’re developing some sort of fibro nodular disease. So I don’t know, I think you need a better graphic ‘cause that’s not what lungs that smoke look like. You don’t have fibro nodular disease, you have holes, right, and you’re not showing that.” (R2, C2) |
Preference for intuitive display (patients) | “Yeah, you see the bronchia, which, you know, in the others, it’s more congested. You can’t see it. So that I got.” (R1, P1) “Just flop them so your darker lung is at the bottom.” (R1, P3) |
2. Tool Design | |
Importance of engaging design | “Yeah, because this—the graph and the way it’s set up is—it’s kind of blah, frankly. You want something to grab you there. This is—like, I mean, it’s like a—one of those Rothko paintings. It’s just white with a little dot or something, you know. It’s not grabby enough.” (R1, P2) “There is no focal point on this. Usually with an infographic, you’re supposed to have a focal point that draws you in. There is no focal point here.” (R2, C2) |
Preference for minimalist design | “You make me—when you ask me what I’m taking home from it, essentially I’m taking home the whole thing, the whole top. If there was too much information on it […] [it would] be in overload […] So yeah, I think it’s very effective in that way,that it doesn’t go overboard. Doesn’t give you too much info. But it gives you enough to think about.” (R1, P2) “It’s really busy. It’s too much stuff. That’s my first thought.” (R2, C2) |
Preference for large fonts and visual elements | “Print’s too small.” (R1, P5) “It is way too small.” (R1, P3) “And it’s too crowded.” (R1, P5) “It’s too small […] The problem for me right now is in black and white, I’m not being drawn to the key message. I want to see these two lines, you know, Jane quit smoking, Jane continues smoking, those should be bigger.” (R2, C2) |
Preferences for use of colours | “I would say something that’s more colourful.” (R1, P4) “It’s true, we are very visual, you know what I mean, and red, danger and certain things like that, right.” (R1, P3) “I think that this being in colour, even though it’s being more expensive, I think that would be really nice, especially for the graph parts of the– it’s just like a much more clearer relation of the stages, you know, just to colour code it.” (R4, C4) |
3. Advantages of Infographic Messaging | |
(a) Overall power of visual depictions | Yeah, [if this was] tied to the lung function test? Absolutely, this is a visual of what that is in layman’s terms.” (R2, P4) |
(b) Function of anchoring to evidence | “This is objective evidence. So I think that would be very helpful in that regard.” (R2, C2) “…everything that’s been recommended here has been validated and shown to be helpful in some patient populations.…for the doctor to be able to say, we know these work.” (R2, C2) |
(c) Accessibility to low literacy and non-English speaking populations | “A lot of my patients will take notes, because many of them don’t speak English…So for my population, where I would be using this, I prefer something where they’ve got a pen and they can scribble all over it.” (R2, C2) |
4. Impact of Tool on Determinants of Smoking Cessation Advice Delivery | |
(a) Impact on barriers to smoking cessation advice delivery | |
Tool acts as a reminder to deliver smoking cessation advice | “And it’s a reminder, right, so it’s almost like you’ve done a PFT, COPD, this is on there. It’s like a constant reminder to also talk to those patients that you’ve seen time and time and time again” (R4, C4) |
Tool increases efficiency of smoking cessation advice delivery | “I think not only would you be faster. I think you would be more organized. And I think over time you would actually see even, like, additive benefits of that because you would get more comfortable providing smoking cessation counselling in an organized manner. And in a way that leads you directly from the explaining the relevance to the patient and then kind of going right into the therapeutic options. I think it would be really quick and efficient.” (R1, C1) |
Tool increases impact of smoking cessation advice intervention | “…the fact that the patient would then get this and be able to reference it back and maybe they would stick it on their fridge or have it somewhere where they could look at it and it would continue to motivate them at home after their healthcare visit. And might even make them want to do some of their own reading about the effects of smoking” (R1, C1) |
Effect on relationship with patient (deleterious impact) | “So if someone says I’m not interested in quitting smoking, and then I go on and say, okay John, you told me you don’t want to quit smoking. But let’s talk more about your lungs and what’s going to happen. They’re just going to say, listen, this guy is not hearing me. I told him I don’t want to quit.” (R3, C3) |
Effect on relationship with patient (positive impact) | “…they want information, and this is information. They may not do anything with it, but they really appreciate, they really appreciate somebody sitting down and talking to them.” (R2, C2) |
(b) Enabling impact on smoking cessation advice delivery | |
Ease of access | “… it makes it much easier than having to find something else and print it off and see if you’re in a room that has any posters or pictures. I like tools like this. This is very useful ‘cause I find just ease of access, it’s right there.” (R4, C4) |
Prescription facilitation: reminder of medication doses | “I think it would be helpful. It’s always—you know, it’s just to remember exactly the right dose of nicotine replacement therapy given your patient’s smoking habits.” (R1, C1) |
Prescription facilitation: reminder of medication contraindications | “I don’t do a ton of COPD care as respirologist myself…I would want more information for…the Champix and Zyban. Just at least what to avoid, right.” (R4, C4) |
Prescription facilitation: reminder of medication coverage | “… I think it’s helpful that it has the costs incorporated as well, which are an important piece because they’re not always covered unless you’re in one of these kind of special referral programs…” (R1, C1) |
Role of physician guidance | “I think one of the big advantages of it is that the little graphics, the pictures here, the doctor can actually point to them and say, look, how short of breath are you on a scale of one to ten, or something…The doctor can give you what to look for in stages one to ten by pointing to a particular activity” (R1, P2) |
5. Barriers and enablers to quitting | |
(a) Barriers to quitting | |
Financial | “But even on the left here, Chantix all that, $384 for 8 weeks of (R4, P2)—“Who’s got that kind of money?…They want you to quit, but it’s so expensive to quit.” (R4, P5) |
Fear of mediation side-effects/dependency | “…I broke out. I did, you know, right arm, left arm, chest, the whole bit to the point where I had to go to a dermatologist. I tried another couple of patches and still had a problem…” (R2, P2) |
Perceived futility of quitting when predicted GOLD stage does not change with smoking cessation | “So in the scenario where you may end up in the same stage whether or not you quit, do you think that you’d still be compelled to quit smoking if you saw that? (R2, M) “I’d be—yeah, number two, less compelled.” (R4, P2) “Yeah, I wouldn’t quit.” (R4, P6) |
Patient not being in the Active Stage of Quitting | “Maybe I can quit. But it took a long time. It took two years to get myself to a spot where I can honestly say I quit smoking.” (R2, P2) |
(b) Enablers to quitting | |
Fear of worsening functional capacity | “Homecare that you’d need. Possibility of being in a wheelchair or having to use oxygen tanks. Just, you know what, losing your ability to be independent is terrifying.” (R1, P3) “I find the fear of my patients who have COPD are smoking, are petrified of being on oxygen…” (R3, C3) |
Fear of worsening lung function | “I think the lungs because you feel it. You feel that your lung’s not—hasn’t got the capacity.” (R3, P5) “I could turn around a lot of people who are in stage one and open their eyes as to what stage two is, because…here’s stage two and it creeps up on you. And that’s the thing about the disease, you really don’t notice it. It just creeps up on you.” (R3, P2) |
Fear of frequent flare-ups | “That’s not something that you can just get a script in the emerge and you’re okay…It’s not just a simple tablet you take once in awhile when you show up in the emergency department. Yes, you do for a flare but it shouldn’t be that that’s the message they’re getting. It should be, like, you’re ending up in the emerge a lot and you’re sick, you know.” (R4, C4) |
Fear of death | “…The mention of death is more effective.” (R4, P4) |
Physical depictions of lung deterioration | “… Just black out that part of the lung that’s gone dead, if you like… a picture would show only a third of a lung in clear and the rest of it’s black or greyed out…I just think it would be more dramatic, be more impactful…” (R3, P5) |
Diverse smoking cessation pharmacotherapy options and resources | “Oh, smokers help line…in fact, I would put that at the top before anything to know that there was some place that you could definitely go.” (R2, P1) |