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Published on: October 6, 2016
Process evaluation exploring implementation and delivery of a home-based extended exercise intervention for older
Abi J Hall1, Friederike Ziegler2, Matthew Prescott2
1Public Health and Sports Science Department, University of Exeter, Exeter, UK.
Background:
Frailty is an especially significant consequence of ageing with resulting physical decline. Some studies suggest that exercise can reduce the deleterious effects of ageing and have a positive impact on functional ability and quality of life. Further research was required to determine the clinical effectiveness and cost-effectiveness of extended community-based rehabilitation for older people following acute illness or injury. The Home-based Extended Rehabilitation for Older people trial included an embedded process evaluation and compared provision of a home-based graded exercise programme plus usual care (the Home-based Older People's Exercise intervention) versus usual care alone for community-dwelling older people with frailty.
Methods:
Qualitative mixed-methods process evaluation incorporating non-participant observations, semistructured interviews and analysis of therapy records and participants' exercise diaries. Primary aims of the process evaluation were to explore fidelity and acceptability in intervention delivery. Data analysis was based on thematic analysis and was underpinned by Normalisation Process Theory.
Results:
Data were generated in 10 community services in England. Non-participant observations of 10 staff training sessions, 61 intervention delivery sessions and 8 staff trial update sessions were completed. Semistructured interviews were conducted with 10 therapy service managers, 19 therapists and 4 therapy assistants. Thirty-five interviews were conducted with intervention participants, with some including supporting carers, and 19 with usual care only participants. There was evidence of fidelity to the intervention protocol, with no significant variation between sites. Less experienced therapists were sometimes less confident in making judgements about what exercises could be adapted and tailored to the individual while maintaining intervention fidelity. Most therapists utilised planned behaviour change techniques to engage participants and sustain their involvement in the exercise programme. Intervention acceptability was generally good, with therapy staff and participants noting potential and actual benefits of the intervention and associated physical improvements for participants completing the 24-week intervention. Usual care only participant interviews provided no evidence of engagement with or perceived benefit from community-based programmes provided by the National Health Service or private providers which were equivalent to the Home-based Older People's Exercise intervention. Therapists and therapy service managers noted the value of the Home-based Older People's Exercise intervention as an addition to existing programmes that were designed to reduce the likelihood of older people with frailty requiring hospital admission. However, they felt that embedding the intervention in routine service provision would prove to be challenging within the existing resource allocation.
Limitations:
It was necessary to utilise convenience sampling for some of the data collection. It proved to be difficult to recruit family carers, as many participants lived alone. These issues may have impacted the extent to which participants were fully representative of the population targeted in the Home-based Extended Rehabilitation for Older people trial.
Conclusions:
Home-based Older People's Exercise was perceived to be an acceptable rehabilitation intervention, which could be utilised to extend existing home-based rehabilitation for older people living with frailty. With appropriate resource allocation, it could be delivered by therapists and appropriately trained and supervised therapy assistants in community-based rehabilitation settings.
Future Work:
Research is needed to evaluate the effectiveness of structured, individually tailored, exercise interventions, like Home-based Older People's Exercise, within inpatient and community-based intermediate care settings, recognising the variation in delivery models across health services.
Funding:
This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme as award number 15/43/07.
