Promoting physical activity and physical function in people with long-term conditions in primary care: the Function First realist synthesis with co-design

Background As people age and accumulate long-term conditions, their physical activity and physical function declines, resulting in disability and loss of independence. Primary care is well placed to empower individuals and communities to reduce this decline; however, the best approach is uncertain. Objectives To develop a programme theory to explain the mechanisms through which interventions improve physical activity and physical function in people with long-term conditions in different primary care contexts, and to co-design a prototype intervention. Data sources Systematic literature searches of relevant databases with forwards and backwards citation tracking, grey literature searches and further purposive searches were conducted. Qualitative data were collected through workshops and interviews. Design Realist evidence synthesis and co-design for primary care service innovation. Setting Primary care in Wales and England. Participants Stakeholders included people with long-term conditions, primary care professionals, people working in relevant community roles and researchers. Methods The realist evidence synthesis combined evidence from varied sources of literature with the views, experiences and ideas of stakeholders. The resulting context, mechanism and outcome statements informed three co-design workshops and a knowledge mobilisation workshop for primary care service innovation. Results Five context, mechanism and outcome statements were developed. (1) Improving physical activity and function is not prioritised in primary care (context). If the practice team culture is aligned to the elements of physical literacy (mechanism), then physical activity promotion will become routine and embedded in usual care (outcome). (2) Physical activity promotion is inconsistent and unco-ordinated (context). If specific resources are allocated to physical activity promotion (in combination with a supportive practice culture) (mechanism), then this will improve opportunities to change behaviour (outcome). (3) People with long-term conditions have varying levels of physical function and physical activity, varying attitudes to physical activity and differing access to local resources that enable physical activity (context). If physical activity promotion is adapted to individual needs, preferences and local resources (mechanism), then this will facilitate a sustained improvement in physical activity (outcome). (4) Many primary care practice staff lack the knowledge and confidence to promote physical activity (context). If staff develop an improved sense of capability through education and training (mechanism), then they will increase their engagement with physical activity promotion (outcome). (5) If a programme is credible with patients and professionals (context), then trust and confidence in the programme will develop (mechanism) and more patients and professionals will engage with the programme (outcome). A prototype multicomponent intervention was developed. This consisted of resources to nurture a culture of physical literacy, materials to develop the role of a credible professional who can promote physical activity using a directory of local opportunities and resources to assist with individual behaviour change. Limitations Realist synthesis and co-design is about what works in which contexts, so these resources and practice implications will need to be modified for different primary care contexts. Conclusions We developed a programme theory to explain how physical activity could be promoted in primary care in people with long-term conditions, which informed a prototype intervention.

As people age and develop long-term conditions, their physical function can decline, leading to disability and loss of independence. How can general practices best promote physical activity and reduce this decline? We asked people with long-term conditions, general practice staff and other experts about how to promote physical activity and improve physical function. We combined these ideas with those in research reports and developed ideas (or theories) about how to increase physical activity in people with long-term conditions. We also considered how these theories might work in different circumstances. The five theories are as follows: Consultations in general practice surgeries tend not to prioritise physical activity and function. If the culture of the practice is supportive of physical activity, then encouraging physical activity will become part of the usual routine. Physical activity promotion is inconsistent and unco-ordinated. If physical activity promotion has more resources, then this will improve opportunities to change behaviour. People with long-term conditions have varying physical activity levels, attitudes and opportunities. If physical activity promotion is adapted to individual needs and preferences, then people will be more likely to carry on. Many general practice staff lack knowledge and confidence about promoting physical activity. If training makes staff more capable, then they will be better at promoting physical activity. If a programme makes sense and is trustworthy, then patients and professionals will engage with it. We used these theories to design a new way of working with patients, health professionals and researchers. Resources were created for developing an environment that encourages physical activity, knowledge about physical activity and a new role for someone who can encourage people to use local opportunities to be more active. This product would need to be developed further, considered alongside existing schemes and tested in a future study.