What is the role of primary care in reducing the decline in physical function and physical activity in people with long-term conditions? Findings from realist synthesis with co-design.

The Problem: Declining physical function and physical activity in people with long-term conditions can cause deteriorating physical, social and psychological health, and reduced independence. In line with the renewed declaration from the World Health Organisation, primary care is well placed to empower individuals and communities to reduce this decline. However, current evidence suggests the best approach is uncertain and the complexities of the needs of people with long-term conditions and of primary care service delivery requires further investigation. Therefore, this study aims to unpick this complexity and develop evidence-based recommendations about how primary care can facilitate improved physical function and physical activity for people with long-term conditions. The Approach: Realist evidence synthesis combining evidence from varied sources of literature with the views, experiences and ideas of stakeholders. Established realist methods will develop and refine theories about improving physical function and promoting physical activity for people with long-term conditions. In particular, what works (or does not work), for whom and in what circumstances. We have used LEGO® SERIOUS PLAY® as a participatory method for two theory-building stakeholder workshops, enabling expression and creativity through building models and sharing. These workshops included 13 health and social care professionals, 10 people with long-term conditions and the two lead researchers. We have also incorporated expertise and perspectives from the public contributors on our study team as well as members of our international external Project Advisory Group. The initial theory areas have informed the literature review and the programme theories developed from the literature will inform three co-design workshops for a primary care service innovation. Findings: Initial overarching theory areas from the stakeholder workshops include the promotion of physical literacy and organising care according to the International Classification of Functioning. These can be applied at the level of the individual patient, and further sub-divided into physical, psychological and social components, the individual health professional, the practice, and then wider programmes and localities. For example, value and responsibility for physical activity and function, enjoyment and identity, as well as social support have been identified so far. Following initial title and abstract screening of 20,436 articles, the literature search has identified 2069 articles, which are being selected for inclusion according to relevance and theoretical richness. Selected studies are being mapped against our initial theory areas from which we will develop our final programme theories, which will be described in terms of contexts, mechanisms and outcomes. Implications: This work is important because shifting the emphasis of primary care long-term condition management away from the diagnosis and categorisation of disease towards the promotion of physical activity has the potential to improve physical functioning and independent living. It will have important implications for practice, primary care education and policy.