Abstract
Background
Physical inactivity is rising in the UK adult population, particularly in those with a long-term health condition. 1 People living with chronic lung conditions (e.g. chronic obstructive pulmonary disease, bronchiectasis, pulmonary fibrosis) have lower daily physical activity levels compared to aged-matched healthy populations.2,3
Structured physical activity programmes, such as pulmonary rehabilitation, a face-to-face 6- to 8-week intervention, are one of the key treatments for chronic lung conditions. 4 However, across the UK, there are barriers preventing people with a lung condition from attending these programmes including accessibility, under-referral and long waiting times. 5 Current evidence also suggests that completing short-term structured programmes does not always translate to long-term behaviour change (i.e. daily physical activity). 6
Remote-based interventions, including web and telephone, can support change in physical activity behaviour. 7 These interventions, however, are not readily available for people with a lung condition in the UK. Third-sector organisations such as the British Lung Foundation can support the availability of remote-based interventions targeting physical inactivity in people with lung conditions.
Service Development
The importance for having a theoretical basis for intervention development is well established. 8 The Behaviour Change Wheel (BCW) is a theoretically driven framework designed to enable the systematic development of interventions for supporting behaviour change. 9 At the centre of the framework is the COM-B model, which sets out the need for a change in an individual’s capability, opportunity or motivation for behaviour change to occur. We report the development of a new British Lung Foundation service for physical activity, to be delivered remotely, according to the key stages of the BCW.
Stage 1 (Understanding the behaviour)
The first step in using the BCW requires defining and specifying the target behaviour. National surveys of physical activity in the UK define inactive populations as those completing fewer than 30 minutes of moderate-intensity equivalent physical activity per week. 1 The biggest gain to be made in public health and the best value for public investment is in supporting the people who are least active. 1 As such, increasing the proportion of people with lung conditions who complete more than 30 minutes of physical activity per week was chosen as the focus of this service.
Having specified the target behaviour, the next step was to identify what needed to change (‘behavioural diagnosis’) to achieve the desired behaviour change. This required a full understanding of the barriers and facilitators to physical activity in people with lung conditions.
We performed a review of the literature (using PubMed) to support a behavioural diagnosis. The search strategy was structured around free text terms for the population (e.g. ‘COPD’) and behaviour (e.g. ‘physical activity’). The search retrieved 250 articles, of which 5 were identified as relevant to intervention development. We held a workshop with health and social care professionals (n = 3) and people with lung conditions (n = 3) to further explore the beliefs of key stakeholders. The barriers and facilitators to physical activity were finalised and mapped to the COM-B model (Table 1).
BCW: Behaviour Change Wheel; BCTTv1: Behaviour Change Technique Taxonomy Version 1; BLF: British Lung Foundation.
Behaviour Change Techniques, delivered by a remote service, have been identified as ways to address the intervention functions that are linked to barriers and facilitators of physical activity in people with lung conditions.
Behaviour Change Techniques ‘9.1 Credible source’ applies throughout the intervention as the intervention is delivered by the British Lung Foundation.
Stage 2 (Identifying intervention options)
The next step of the BCW considers nine potential intervention functions that can bring about change in an individual’s capability, opportunity and motivation, and seven policy categories that support the delivery of the intervention functions. An additional review of the literature was conducted to identify the available evidence on remote interventions. PubMed was searched for population terms (as in Stage 1) alongside free text terms for remote interventions (e.g. ‘digital’, ‘text’, ‘phone’, ‘web’, ‘app’). The search returned 1566 results, of which 14 were deemed relevant for further review.
The articles were reviewed for intervention functions, policy categories and behaviour change techniques (BCT) according to the Behaviour Change Technique Taxonomy (BCTTv1). 10 We again consulted our stakeholder group to provide their perspectives. Decision making on intervention functions and policies was an iterative process and informed by the APEASE (affordability, practicability, effectiveness, acceptability, side effects and safety, equity) criteria. The intervention functions of ‘incentivisation’, ‘restriction’ and ‘coercion’ were excluded for not meeting the APEASE criteria. The majority of studies with positive outcomes for physical activity in the existing literature utilised the intervention functions of ‘enablement’ and ‘education’. The functions of ‘training’, ‘environmental restructuring’, ‘modelling’ and ‘persuasion’ were also deemed to be appropriate for addressing what needs to change (Table 1). In terms of delivery of these intervention functions, many policy categories were not deemed practicable or acceptable, including fiscal measures, regulation, legislation and environmental/social planning. Intervention functions delivered through service provision, supported by communications/marketing and use of existing physical activity guidelines were deemed most appropriate.
Stage 3 (Identifying intervention content and implementation)
The final steps were to consider the relevant BCT and delivery mode of the intervention functions. The most frequently used BCT linked to these intervention functions in the extant literature were ‘goal setting (behaviour)’, ‘self-monitoring of behaviour’, ‘social support (unspecified)’, ‘information about social and environmental consequences’ and ‘adding objects to the environment’. Further review of the BCTTv110 and stakeholder discussions identified another 23 BCT that met the APEASE criteria (Table 1). A 12-month telephone (health coaching) intervention for each individual, supported by printed (information pack including an activity diary and wallchart) and digital resources (email newsletters, exercise videos and an optional pedometer), were agreed to be modes of delivery that met the APEASE criteria for people with lung conditions. The implementation of each BCT and the final design of the intervention content are provided in Table 1.
Potential Impact and Implications
The BCW enabled the systematic development of a telephone service for inactive people with lung conditions. The importance of physical activity in management of lung conditions is well recognised. Increased physical activity is associated with improved symptoms and quality of life, and reduced health care use in people with lung conditions. An assessment of the feasibility and potential impact of this new British Lung Foundation service is currently being undertaken in England, with the evaluation framework due to be reported in a subsequent paper. The findings of this evaluation will inform the potential scalability and transferability of this intervention for achieving wider public health impact.
Footnotes
Acknowledgements
The authors would like to thank the following people who have supported this work: Annette Berg, Bethany Bateman, Eric Compton, Hayley Robinson, Louise Stanley, Mark Hinchliffe, Michelle Roberts, Mike McKevitt, Sarah Worbey, Simon Pearce and Vicky Barber.
Conflict of Interest
J.P. was employed by the British Lung Foundation, which funded this work. The remaining authors declare no other conflicts of interest.
Ethical Approval
Defined as usual practice by the Health Research Authority and therefore no research ethics committee approval sought.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: J.P. was employed by the British Lung Foundation, who received funding to complete this research. The authors declare no other conflicts of interest.
